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THE 

SYMPATHETIC DISEASES 



EYE 



LXJDWIG MATJTHNEK, M.D. 

ROYAL PBOFESSOB IK THE UKIVEBSITX OF VlEHftA 



TRANSLATED FROM TBE GERMAN 



WARREN "WEBSTER, M.D. 

BOBOEON, UNITED STATES ABUT 
AND 

JAMES A. SPALDING, M.D. 

MEMBEB OF THE AMEBICAH OPHTHALMOLOGICAL SOCIETY J OPHTHALMIC StfE- 
OEON TO THE MAINE GENERAL HOSPITAL. 



NEW YORK 

WILLIAM WOOD & COMPANY 

18.81 



1U, ? <fxi 






TRANSLATORS' PREFACE. 



This comprehensive monograph, on the Sympa- 
thetic Diseases of the Eye, is the first of a series 
intended to embrace the whole province of Ophthal- 
mology. The author, Dr. Ludwig Mauthner, of 
Vienna, a well-known specialist, has two objects in 
view : one, to compile, for the ophthalmic surgeon, 
the widely diverse opinions on the subjects under 
discussion ; the other, to enable the general practi- 
tioner, and the student in ophthalmology, to gain an 
insight into the pathology, and especially into what 
should be the practical treatment, of the more im- 
portant diseases of the eye. 

Although the number of learned, conscientious, 
and skilled oculists in America is daily increasing, 
yet there will be exigencies in civil life, as well as in 
the military and naval service, when their assistance 
cannot be obtained. A large majority of patients 
affected with diseases or injuries of the eye, should, 
and naturally will, turn at once to their family physi- 
cian for advice. The latter, with this monograph at 
hand, or others of the series as they shall appear, will 



TRANSLATORS PREFACE. 



be enabled immediately to judge of the triviality or 
of the serious nature of the case. He will then de- 
cide either to treat it himself, according to the latest 
light which scientific research and experience, as set 
forth in books, have thrown upon it, or to refer it, if 
haply he can, to a trustworthy specialist for more 
minute treatment, or for an operation, if necessary. 

In so far as regards the subject of the present 
monograph (Sympathetic Diseases of the Eye), we 
may truly say that it is one of the most important 
with which the oculist is ever concerned. Upon his 
correct judgment will generally depend the future 
vision of the patient. Much more urgent, therefore, 
must be the necessity for general practitioners in the 
country, and for medical officers of the army and 
navy, to have at hand a clear and reliable descrip- 
tion of the multiform symptoms, and the treatment, of 
Sympathetic Ophthalmia, so that they may at once 
recognize its presence, and treat it from the outset 
appropriately and effectually. Although cases of this 
nature are comparatively rare, their importance is 
sufficiently great to account for the appearance of this 
excellent work in an English version. 



Warren Webster. 
James A. Spalding. 



Portland, Maine, September 1, 1881. 



AUTHOE'S XOTE. 



These " Lectures on Ophthalmology " cannot fully 
succeed in their professed object of popularizing, 
among practitioners of general medicine, the specialty 
to which the author belongs, unless he assumes that 
the readers have but slight acquaintance with oph- 
thalmological terminology. He regrets, however, that 
he has occasionally been obliged to overstep the 
bounds of general description, and to adopt, for a 
time, the necessary minutiae of his specialty. 

Mauthnee. 
Vienna, March 27, 1878. 



CONTENTS. 



PAGE 

Pkeliminaby Bemakks, 9 

SECTION I. 
Anatomy, 12 

SECTION II. 
Etiology, IT 

SECTION III. 
Pathology, 56 

SECTION IV. 
Pathogeny, 105 

SECTION V. 
Thebapetjtics, 146 

Index, 209 



THE 



SYMPATHETIC DISEASES OF THE EYE. 



It is a terrible thing when some constitutional dis- 
ease, or a local disease outside the eye — perhaps of 
the brain — or some definite disease of the eye itself, or 
a traumatic agent, destroys the sight of both eyes at 
once. Then, again, it is lamentable when one eye is 
destroyed, at a greater or less interval after the other, 
from a repetition of the original injury, as has twice 
occurred in my experience, from the explosion of gun- 
powder, and the thrust of a cow's horn. The misfor- 
tune, however, is even more aggravated when the 
second eye is totally lost, simply from some disease or 
injury of the first eye; or when a surgical operation 
on the one eye not only fails of its object, but subjects 
the opposite eye to serious mischief ; or when, after a 
successful operation on one eye, ws attempt at a later 
date to gain some vision for the other, and not only 

find that the second eye is unimproved by the attempt, 
1* 



10 SYMPATHETIC DISEASES OF THE EYE. 

but also that, as a direct consequence of the last opera- 
tion, the sight once happily restored to the first eye is 
again imperilled. 

" Sympathetic ophthalmia " is a general term, which 
serves to designate, not a particular affection, but a 
whole series of ocular lesions, which differ from one 
another in their seat and manifestations, but always 
have a common origin. When an eye is laboring un- 
der injury or disease, it frequently happens that the 
other eye, which has hitherto been healthy, becomes, 
after a certain time, and without apparent cause, the 
seat of various functional or structural disturbances. 
The latter are called sympathetic affections, and, taken 
together, constitute sympathetic ophthalmia. Those 
diseases, therefore, which are superinduced in the 
second eye, upon an injury, or a disease, of the first 
eye, and which can be traced to no other cause than 
the original injury or disease, are regarded as sym- 
pathetic diseases. 

Hardly any other province of ophthalmology is of 
more practical importance, and in no other are greater 
demands made, as well on the personal experience of 
the practitioner, as on his acquaintance with the expe- 
rience of -others; in hardly a second field is greater 
good to be expected from treatment, or greater evil 
from neglect, than in the one comprising the sympa- 
thetic diseases of the eye. Here it is not the fate of 
a single eye that is at stake, but the question that al- 



SYMPATHETIC DI8EA8ES OF THE EYE. 11 

most always confronts us is: Shall the individual suf- 
fer utter loss of sight, or shall the vision of at least one 
eye be wholly, or in part, preserved ? 

Before describing the symptoms of sympathetic 
affections of the eye, and their treatment, we must 
notice the primary injuries and diseases of the eye 
which most commonly excite sympathetic disturbances. 
First, however, it will be well to refresh, in a brief 
manner, our remembrance of the anatomical structure 
of the eyeball. 



SECTION I. 



ANATOMY. 

The eyeball is composed of several investing tunics, 
as well as of fluid and solid contents, called the refract- 
ing media. The most important of the latter is the 
crystalline lens, which is a double convex body, situ- 
ated immediately behind the pupil, and having its 
axis in the same line with that of the eyeball itself. 
It is retained in its position chiefly by the suspensory 
ligament (zonula Zinnii), which connects its periph- 
ery with the anterior margin of the retina. The sus- 
pensory ligament is also attached to the ciliary body 
by a series of radiating folds or plaitings, into which 
the corresponding ciliary processes are received. 

The vitreous humor, which occupies about four- 
fifths of the eyeball posteriorly, is surrounded by the 
retina as far forward as the termination of the latter, 
at the ora serrata, and is bounded, in front, by the cil- 
iary body, the zonula of Zinn, and the posterior cap-' 
sule of the lens. 

That portion of the cavity of the eyeball which lies 
in front of the lens, between the latter and the cornea, 



ANATOMY. 13 

is occupied by the aqueous humor. This space is di- 
vided into the anterior and posterior chambers by the 
iris, a thin, membranous curtain, banging vertically in 
front of the lens, and perforated by the pupil for the 
transmission of light. The iris may be regarded as a 
process of the choroid, with which it is continuous, 
although there are differences of structure in the two 
membranes. The anterior chamber is bounded in 
front by the cornea, a perfectly transparent tissue, the 
innermost layer of which is a single stratum of fiat, 
epithelial cells, which rest on the membrane of Desoe- 
met, and are bathed by the aqueous humor. The 
anterior chamber is bounded posteriorly by the ciliary 
ligament and the iris, and by that portion of the an- 
terior capsule of the lens which lies free in the pupil. 

At the place where the periphery of the cornea is 
overlaid, like a watch-glass, by the free edge of the 
sclerotica, a multitude of stiff fibrillae stretch across, 
in a curved direction, from the inner surface of the 
cornea to the front of the iris, and constitute collect- 
ively the ligamentum pectinatum iridis. The epithe- 
lial cells covering the membrane of Descemet are 
continued upon the ligamentum pectinatum, where 
they form, in conjunction with the fibrillae of the 
latter, a cellular plate, which separates the anterior 
chamber from the ciliary body. 

The whole posterior surface of the iris does not lie 
directly in contact with the anterior capsule of the 



14 SYMPATHETIC DISEASES OF THE EYE. 

lens, but only the central portion, that is to say, the 
pupillary border. Hence, as the iris occupies a nearly 
level plane, its periphery is separated from the ante- 
rior convex snrface of the lens, and the space known 
as the posterior chamber is formed. The individual 
ciliary processes project into the angle of the posterior 
chamber, in the region of the sclerotica. The poste- 
rior chamber is bounded in front by the iris, with its 
thick covering of pigment ; whilst its posterior wall is 
made up of the anterior capsule of the lens, the zonula 
of Zinu, and the ciliary processes. 

Inasmuch as the pupillary margin of the iris, in a 
healthy eye, moves freely over the anterior capsule of 
the lens, no obstacle exists to an interchange of the 
fluid contents of the anterior and posterior chambers ; 
indeed, if the pupil be dilated by the instillation of 
atropia, so that the border of the pupil can no longer 
touch the anterior capsule, the two chambers become 
practically blended into one. 

The retina is a delicate, semi-transparent expansion 
of the optic nerve, and extends nearly as far forward 
as the ciliary muscle, where it terminates by a jagged 
margin, the ora serrata. Its outer surface lies in con- 
tact with the pigmentary layer of the choroid ; its 
inner surface, with the vitreous body. The optic nerve 
pierces the sclerotic and choroid coats at the back part 
of the eyeball, and enters its cavity at a spot called the 
optic papilla, a little to the nasal side of its posterior 



ANATOMY. 15 

pole. On examining the concave inner surface of the 
retina, we observe, directly in a line with the axis of 
the globe, and situated about three millimetres out- 
ward from the optic papilla, a circular yellow spot, 
which presents a central depression {fovea centralis), 
in which the sense of vision attains its greatest per- . 
fection. A horizontal section of an eyeball, accurately 
dividing the optic papilla into an upper and a lower 
half, would not bisect the fovea centralis, which lies in 
a plane slightly below the papilla. 

The choroid is the vascular membrane of the eye, 
and, with the ciliary body and iris, constitutes the uve- 
al tract. It is interposed between the sclerotica and 
the retina, and is thinner than either of these tunics ; 
but its important appendage, the ciliary body, which 
lies next to it in front, attains a considerable size, 
being about four millimetres thick from before back- 
ward. This body — which is made up of the zonula of 
Zinn, the ciliary processes, and the ciliary muscle— is 
divisible into two parts: the inner portion consists of 
the zonula and the ciliary processes ; the outer por- 
tion (which was formerly regarded as a ligament, but 
in which the existence of muscular fibres has been 
demonstrated by Briicke, Bowman, and Miiller) oc- 
cupies the space between the scleral insertion of the 
cornea and the periphery of the iris. The ciliary mus- 
cle is united externally with the cornea and sclerotica, 
and, internally, merges into the ciliary processes ; be- 



16 SYMPATHETIC DISEASES OF THE EYE. 

hind, it is continuous with the choroid, and, in front, 
is inserted, by a portion of its fibres, into the iris, 
whilst by others it is attached to the wall of the canal 
of Schlemm and to the ligamentum pectinatum iridis. 
The contraction of the ciliary muscle draws the cho- 
roid forward and (by aid of its circular fibres) inward, 
toward the equator of the lens. 

During youthful life, or so long as the lens remains 
soft, its form is regulated by the degree of tension 
maintained in its capsule by the suspensory ligament. 
When the latter is relaxed, by the action of the ciliary 
muscle, the lens retracts by its own elasticity, and 
becomes more globular in shape, thereby increasing 
the refractive power of the dioptric apparatus of the 
eye. In a word, it is the office of the ciliary muscle 
to effect that adjustment of the eye (accommodation) 
for near and remote objects, which enables it to pro- 
duce distinct images on the retina. 

If we pass a probe from the outermost edge of the 
anterior chamber, through the ligamentum pectinatum 
iridis, into the ciliary body, we penetrate, beneath the 
cellular plate, a coarse-meshed net-work, lined with 
cells, analogous to the canal of Fontana, as found in 
the ox. This structure is to be distinguished from a 
circular canal, filled with venous blood, and called the 
canal of Schlemm, which is tunnelled out of the scleral 
tissue, around the margin of the cornea, and resembles, 
iu places, a plexus of veins. 



SECTION II. 



ETIOLOGY. 

The ciliary body is copiously supplied with nerves 
and vessels, and may be called the dangerous region 
of the eye — the one from which most of the sympa- 
thetic affections of the second eye proceed. 

The diseases of the ciliary body may arise either 
spontaneously or from traumatic causes. The asso- 
ciation of a wound with the morbid process does not 
necessarily expose the. second eye to increased danger. 
Nevertheless, a graver danger has been attached to the 
traumatic affections of the ciliary body, not only be- 
cause they are more frequent than the idiopathic, but 
from the fact that when a foreign body remains in the 
eye the traumatic affections are less easily controlled, 
or, when apparently under control, are more readily 
rekindled. Wounds of the ciliary body should, in- 
deed, excite solicitude, for they may, at longer or 
Bhorter intervals, inflict on both eyes the most unfor- 
tunate consequences. On the other hand, very serious 
accidents to the ciliary body have, under surgical 



18 SYMPATHETIC DISEASES OP THE EYE. 

treatment, or through some lucky and unforeseen acci- 
dent, or oven spontaneously, terminated in the recov- 
ery of the injured eye, without the implication of its 
fellow. 

A patient caino to mo complaining- that he had in- 
jured himself at smith-work, and that a piece of iron 
had certainly entered his eye. A small wound was 
visible in the upper and outor part of the sclerotica, 
near the margin of the cornea. The eye wept, showed 
slight episcleral injection around the cornea, and was 
sensitive to pressure at the wounded spot. A more 
careful examination showed that the lens was appar- 
ently clear and uninjured ; no deeper wound nor per- 
foration of the anterior chamber could bo discovered. 
It was possible, however, that a small foreign body 
had penetrated the eyeball and still remained at the 
bottom of the wound. 1'erhaps it was lodged in the 
ciliary body, and, in that case, the inilainnialion ex- 
cited therein (cyclitis) might endanger both the in- 
jured and the sound eye. A lino bistouri, introduced 
into the wound, under anaesthesia, encountered some 
metallic body. The wound was at once enlarged, and 
a small chip of iron removed with delicate forceps. 
All the signs of irritation disappeared with exceeding 
rapidity, the wound healed in a few days, and no sen- 
sitiveness whatever of tho ciliary body remained. 

In a second ease, the patient had severely wounded 
his right eye while discharging a musket. Jle averred, 



ETIOLOGY. 19 

with the utmost confidence, that no foreign body was 
lodged in the eye. But it was evident that a perfora- 
tion, located in the centre of the cornea, had been 
made by a bit of an exploded percussion-cap. Had 
the fragment rebounded from the capsule of the lens, 
or had it, perchance, penetrated the lens itself 1 These 
points could not be then determined, for a large amount 
of pus occupied the anterior chamber and concealed the 
pupil. The iris was prolapsed into a puncture, which 
had been made iu the lower border of the cornea for 
the purpose of evacuating the pus. It was in this con- 
dition that I first saw the patient. It was impossible, 
at that time, to decide whether the purulent masses 
which still occupied the pupil were nodules of exuda- 
tion upon the anterior capsule, or were swollen and 
suppurating fragments of the wounded lens ; the lat- 
ter condition, however, seemed the more probable. 
Nevertheless, the pus gradually disappeared, and al- 
though the pupillary border of the iris was found ex- 
tensively adherent to the anterior capsule, neither the 
latter nor the lens had been wounded. The eye con- 
tinued to improve, but, along with some lachrymation 
and pain, a slight subconjunctival injection persisted 
around the dark-colored spot where the iris had pro- 
lapsed. One day, while examining the eye more care- 
fully, iu order to discover the cause of the obstinate 
irritation, I noticed that the dark prolapsed iris had 
a distinct metallic lustre, so that 1 at once suspected 



20 SYMPATHETIC DISEASES OF THE EYE. 

the presence of a piece of metal. With a pair of fine 
forceps I extracted, from a small excavation in the 
corneal edge of the sclerotica, where it lay imbedded, 
a rolled up piece of copper cap, 4 mm. long and 2f 
mm. wide. All the signs of irritation now disap- 
peared in a very short time. A fortunate accident 
had saved both the wounded eye and its mate. The 
piece of metal had penetrated the cornea, struck the 
anterior capsule of the lens without opening it, and 
had then rebounded to the bottom of the posterior 
chamber, where it lay directly upon the ciliary body 
and excited a severe inflammation of the whole ante- 
rior part of the eyeball. The puncture of the cornea, 
which had been made for the removal of the pus from 
the anterior chamber, having luckily been unskilfully 
performed, a portion of the iris fell through the inci- 
sion, and into the poc7cet-like dujplicature thus made 
the piece of metal was received. After necrosis of the 
prolapsed iris the metal lay freely exposed at the edge 
of the cornea. Had the operation been made accord- 
ing to rule the iris would not have prolapsed, and the 
foreign body left within the globe would, in all prob- 
ability, have produced a dangerous cyclitis, with the 
chance of involving the second eye. 

The good results attained in the two injuries just 
described were due to surgical interference : in the 
one case, intentional, and, in the other, accidental. 
But sometimes severe wounds of the eye may termi- 



ETIOLOGY. 21 

uate favorably, without any surgical interference what- 
ever. A boy, twelve years old, was shot in the left 
eye with an arrow from the cross-bow of a playmate. 
The arrow stuck fast in the eye until pulled out by his 
companion. The eye reddened, but was not painful 
at first, and, immediately after the accident, the boy 
said that his sight was as good as ever. Four days 
later, on awaking from sleep, he noticed that he could 
see very little with the wounded eye, and, later in the 
same day, pain supervened, with almost complete blind- 
ness of the eye. On the next day the eye was exam- 
ined by a surgeon, who found a small, round wound in 
the sclerotica, behind the lower and inner edge of the 
cornea. There was also pericorneal injection; the pu- 
pil was contracted ; the unwounded lens was in its 
proper position ; but the vitreous humor was clouded 
throughout. The tension* of the eyeball was normal, 
and no spot manifested any sensitiveness to the touch ; 
but the vision was so reduced that light and darkness 
could barely be distinguished. The inflammatory 
symptoms soon became more marked, and pus, which 
must have come from the ciliary body, inasmuch as 
both cornea and iris were uninflamed, appeared in the 



* By the word tension^ which will be of frequent recurrence in 
these pages, we mean the feeling of hardness or softness of the 
eyeball, when we press upon it through the closed lidB with the fin- 
gers. If the eye feels softer than the normal organ, we say the 
tension is diminished ; if harder, the tension is increased. — Trs. 



22 SYMPATHETIC DISEASES OF THE EYE. 

anterior chamber. Gradually, however, all the inflam- 
matory symptoms subsided, and the turbid vitreous 
again became clear. Two years later, when I saw the 
boy for the last time, the ophthalmoscope revealed a 
very striking condition of things in the fundus of the 
eye. The retina, as well as all the rest of the interior 
of the eye, was visible, although somewhat indistinct. 
A large, dark cord extended from the optic papilla, di- 
rectly through the vitreous body, to the point where 
the arrow had entered the eye. Immediately before 
its termination at this point, the cord divided into nu- 
merous slender threads. Its direction indicated the 
exact course of the arrow-head, which had, therefore, 
traversed the whole vitreous humor and become fixed 
in the optic papilla. A vascular neoplasm, which pro- 
jected toward the vitreous, from near the insertion of 
the cord, appeared to have been due to the irritation 
in the papilla by the foreign body. The eye was free 
from any symptoms of irritation, and showed two-sev- 
enths of the normal amount of vision, with a perfectly 
clear visual field. 

We now have to note another important point. A 
foreign body imprisoned in the eye may prove a source 
of constant irritation for years, exciting from time 
to time severe inflammation of the wounded eye, and 
justifying the fear that sympathetic disease may at any 
time break out in the sound eye. If, however, during 
a violent attack of inflammation, the eyeball should 



ETIOLOGY. 23 

unexpectedly open at some point, and the foreign 
body, so long present, be expelled from the eye, either 
spontaneously or by surgical assistance, a new and 
happy turn may be given to the case, affording perma- 
nent rest to the injured eye, and assuring the other 
from threatened destruction. I have, however, seen 
this favorable result but twice, the offending body, in 
each instance, being a fragment of glass. 

In one case, a piece of glass— so large as to ex- 
cite wonder that it could have either entered or occu- 
pied the cavity of the eyeball — came to light, after a 
violent inflammatory attack, and was finally extracted 
through the sclerotica, after the spontaneous opening 
had been greatly enlarged. 

The second case was that of a woman who applied 
for an artificial eye. A splinter of glass had flown into 
her left eye, in early youth, and had ever since been a 
source of constant irritation, provoking severe inflam- 
matory attacks in the affected eye, and greatly impair- 
ing the vision of the opposite eye. She reported that, 
during a violent inflammatory exacerbation, the splinter 
had appeared at the surface and been spontaneously 
expelled. After that event the injured eye gave no 
further trouble, and the second eye could be used for 
all sorts of work. 

The injuries of the ciliary body and its vicinity, 
known to give rise to sympathetic disease, are appro- 
priately classified as accidental and operative injuries. 



24 SYMPATHETIC DISEASES OF THE EYE. 

The first of these divisions comprises : penetration of 
foreign bodies into the ciliary body, with lodgement 
therein ; punctured or incised wounds of the ciliary 
body, without lodgement of a foreign body ; contused 
or lacerated wounds of the ciliary body, inflicted by 
blunt agents ; incised, punctured, and lacerated wounds 
of the periphery of the cornea, with or without injury 
of the ciliary body, whereby the periphery of the iris 
alone, or along with it a portion of the ciliary body, 
becomes incarcerated in the wound ; and finally, con- 
tusions of the ciliary body, from mechanical violence 
applied to the eyeball, without opening it. 

A foreign object lodged in the ciliary body may some- 
times become eucapsuled, and so be made innocuous. 
When this happens, the diagnosis of its presence is 
certainly very difficult. Bowen, however, has observed 
(1875) that such an object, after a long and harmless 
stay, may suddenly and dangerously announce its 
presence. A particle of iron, the size of a pin-head, 
lay among the fibres of the ciliary muscle for nine 
years, causing extensive thickening in its neighbor- 
hood, as was found at a subsequent examination. After 
this long period, pain in the ciliary body was felt, on 
pressing the spot where the injury had been inflicted s 
and, a few weeks later, sympathetic ophthalmia super- 
vened, which only ceased after enucleation of the 
wounded eye. 

It thus appears certain that a foreign body, either 



ETIOLOGY. 25 

free or encapsnled, may harmlessly remain for a long 
time, and even for life, not only in the ciliary body, 
but in any other part of the eye. It is, on the other 
hand, no less clear, from another case, also reported 
by Bowen (1875), that the wounded eye, even after a 
very protracted interval of quiescence, gains no certain 
immunity from severe inflammation and ensuing 
sympathetic disturbance, liable, as they both are, to be 
caused by the presence of the original foreign body. 
In the latter case, a piece of metal, two and a half 
millimetres long, lay imbedded in the optic nerve for 
seventeen yesars, and it was only after it had produced 
inflammation and disorganization of the uveal tract, 
that sympathetic phenomena — intolerance of light, cil- 
iary injection, and discoloration of the iris — appeared 
in the uninjured eye. 

Although the injuries of the ciliary body are much 
more dangerous than analogous injuries of other parts 
of the eye, from the greater proneness of the former 
to develop the severe train of symptoms presently to 
be described, yet a simple injury of the ciliary body, 
when not complicated by prolapse of the iris, or in- 
carceration of some portion of the ciliary body in a 
penetrating wound, is not often followed by serious 
consequences. 

Violent contusions and concussions, inflicted upon 

the eye by blunt bodies — for example, the naked fist, 

or one in which the fingers are covered with heavy 
2 



26 SYMPATHETIC DISEASES 0E THE EYE. 

rings — play relatively the most frequent part in the 
etiology of cyclitis, and its associate diseases, irido- 
cyclitis and irido-cyclo-choroiditis. Next in order 
of frequency come penetrating and cutting wounds, 
without prolapse or constriction of any of the parts ; 
and least frequently of all (whatever may be their in- 
herent danger), the penetration and permanent loca- 
tion of small foreign bodies within the ciliary body. 

The symptoms and anatomical changes set on foot 
by injuries of the cffliary body may be so insidious and 
painless, at the start, as to be quite unrecognizable. 
Soon, however, more marked symptoms appear : the 
injured eye becomes intolerant of light and bathed in 
tears, while a ring of blood-vessels environs the cornea. 
If we touch the ciliary region with a blunt probe, or 
simply press with the finger through the closed lids, 
the patient complains of its sensitiveness, and, in par- 
ticular spots, of acute pain. The cornea becomes hazy 
and dull on its external surface, and the iris, if visible 
through the cornea, is seen to be discolored, its nat- 
ural lustre gone, and its striated appearance obscured. 
The pupil is still open, but atropia no longer exerts 
any influence upon its size. We soon discover foun- 
dation for our suspicion that the pupillary edge of the 
iris is adherent to the capsule of the lens ; while the 
whole posterior chamber is filled with inflammatory 
exudation, gluing the iris, the ciliary body, and the an- 
terior capsule firmly together. Pus may occupy the 



ETIOLOGY. 27 

floor of the anterior chamber, having forced its way di- 
rectly thither from the ciliary body, through the liga- 
mentum pectinatum iridis and its cellular plate. If the 
pupil be still sufficiently clear to permit of the use of 
the ophthalmoscope, we can with difficulty distinguish 
the fundus of the eye through the intervening tur- 
bidness. So long as this opacity is still diffuse, it is 
hard for the observer to decide how much of it de- 
pends on the cornea, as well as on the turbid aqueous 
full of pus-corpuscles, or how much on the vitreous. 
But when dark objects, of varying size and shape, 
float about in the affected eye upon its being quickly 
moved to and fro, we know that the vitreous humor is 
involved in the pathological process. Vision, mean- 
while, has diminished exceedingly. 

The eyeball now becomes ominously soft to the 
touch, and the acuteness of vision markedly diminished. 
The anterior chamber is narrowed, inasmuch as the 
lens is pushed forward toward the already turbid and 
flattened cornea. The periphery of the chamber may, 
however, appear deeper at places than normal, inas- 
much as the masses of exudation which occupy the 
posterior chamber have formed a cicatricial tissue be- 
tween the iris and anterior capsule, become consoli- 
dated, and so dragged the ciliary border of the iris 
backward toward the lens. The iris itself, having 
passed through its stage of proliferation and soften- 
ing, is now atrophied, and turned to a dirty yellow 



28 SYMPATHETIC DISEASES OF THE EYE. 

color. The black pigment which lines its posterior 
surface is visible through the anterior layer, giving it a 
dotted appearance, while here and there tortuous veins 
are displayed, owing to the inflammatory swelling 
of the ciliary body, whereby the venous blood of the 
iris is now impeded in its passage to the choroid. The 
pupil may, at this stage, be still permeable for light, 
but more frequently it is blocked with masses of ex- 
udation. 

The morbid process culminates when the inflam- 
mation of the ciliary body (cyclitis) is communicated 
backward to the choroid (choroiditis), which, in turn, 
involves the contiguous retina (retinitis), whilst the 
nutrition of the deeper structures of the eye becomes 
so disturbed that a marked reduction in the mass of 
the vitreous humor takes place. The direct conse- 
quence of the atrophy of the vitreous is the loss of 
the normal tension of the globe, which now feels soft, 
and may become so flaccid as to be indented at. the 
places corresponding to the recti muscles. But even 
after phthisis of the entire eyeball, with total inflam- 
matory destruction, or even detachment, of the retina, 
and. consequent extinction of vision, the eye does not 
subside into quiescence. The offending ciliary region 
may still be tender and irritable to the touch, painful 
upon the slightest occasion, and a source of constantly 
impending danger to the other eye. 

"We have, moreover, to mention Mooren's assertion 



ETIOLOGY. 29 

that after the introductory symptoms, such as peri- 
corneal injection, photophobia, lachrymation, and par- 
tial sensitiveness of the ciliary body, in a typical case 
of simple acute eyclitis, we first see an increase of 
depth in the anterior chamber, due to the inflamma- 
tory adhesion of the periphery of the iris to the ciliary 
body. We are also struck by the fact that no iritic 
adhesions to the anterior capsule, even at the pupil- 
lary border, exist at this time, the pupil being readily 
dilatable by the instillation of atropia. Should the 
retraction of the periphery of the iris progress, then 
the veins of the iris dilate, the aqueous humor becomes 
cloudy, pus appears in the anterior chamber, and opa- 
cities quickly and copiously form in the vitreous humor. 
When, in connection with an injury of the ciliary 
body, the eyeball is opened by a punctured or incised 
wound, or is lacerated and contused by some blunt 
instrument (cow's horn), or a projectile, the injury is 
usually complicated by a prolapse, into the wound, of 
a portion of the ciliary body, or the periphery of the 
iris, or both together. In the majority of such cases, 
the eyclitis, or irido-cyclitis, is directly produced by 
the injury, and not by the incarceration of the ciliary 
body or iris. Wounds of this kind are sometimes very 
remarkable. I once saw an eye that had been bitten 
by a horse, so that the organ was lost, after violent 
symptoms of eyclitis, and the other eye subsequently 
suffered from severe sympathetic ophthalmia. Lebrun 



30 SYMPATHETIC DISEASES OF THE EYE. 

(1870) reported a case in which a leech, applied to the 
neighborhood of an eye for therapeutical purposes, 
strayed to the edge of the cornea, where it inflicted a 
bite that was followed by sympathetic symptoms in 
the other eye. We have already mentioned (page 20) 
an extraordinary case in which a foreign body flew 
through the cornea, as far backward as the anterior 
capsule, from which it fell to the floor of the posterior 
chamber, and there rested in menacing contact with 
the ciliary body. 

Both contusions and perforations of the eyeball may 
cause cyclitis in an indirect way. Thus, a contusion 
may partially lacerate the suspensory ligament (zonula 
Zinnii), so that the lens may either sink downward 
upon the ciliary body, and excite irritation by its con- 
tact with the latter, or it may drag upon the ciliary 
body through its remaining attachments to the zonula, 
and produce a similar effect. Again, when a foreign 
body has penetrated the lens, or extensively lacerated 
its capsule, the fragments of the mutilated lens may 
fall into the bottom of the posterior chamber, and 
cause severe inflammation of the iris and ciliary body. 
If, however, the fragments of the lens fall into the 
anterior chamber, their presence usually provokes 
much less inflammation. Thus may injuries of the eye 
lead indirectly, through lesions of the lenticular appa- 
ratus, to disease of the uveal tract, and, later, to sym- 
pathetic affections of the opposite eye. 



ETIOLOGY. 31 

"We rmist here remind ourselves that it is not only the 
accidental injuries of the eye, but also those which are 
incidental to surgioal operations, that may initiate 
sympathetic ophthalmia. Among the operative inju- 
ries, the one called iridodesis, and the various opera- 
tions for cataract, occupy the first rank. Critchett 
(1858) devised the operation of iridodesis, with a view 
to provide the disabled eye, under certain circumstan- 
ces, with better vision than could be gained by iridec- 
tomy. 

The operation called iridectomy consists in making 
a new opening in the iris for the rays of light to enter 
the eye, when the natural pupil is covered by a central 
opacity of the cornea, or when the pupil lies in front 
of a stationary central cataract. A piece of the iris is 
excised, so that a portion of the still transparent cornea, 
or lens, faces the artificial opening. This operation, 
when performed for optical purposes only, has not 
usually given satisfactory results. It is, indeed, in- 
valuable when the central opacity of the cornea wholly 
conceals the pupil, and is at the same time completely 
or nearly opaque, provided that the outer portion of 
the cornea, which appears normal, is really so, as re- 
gards both transparency and curvature. Moreover, in 
the rare disease called stationary nuclear cataract, in 
which the central portion of the lens lying directly 
behind the pupil is totally opaque, and a considerable 
margin of the lens beyond the opacity is perfectly 



32 SYMPATHETIC DISEASES OF THE EYE. 

transparent, iridectomy is a reliable resource. I 
such clear indications for the operation are seld< 
met with, for the offending spot in the centre of f 
cornea oftentimes falls far short of complete opaci 
whilst the central cataract, on account of which t 
patient demands " more light," is almost always of t 
so-called lamellar variety, in which an opaque lame 
or zone intervenes between the nucleus and cortic 
portion, which are both clear. In many cases t 
impairment of vision is so slight as not at all to int< 
fere with ordinary pursuits, and no surgical operate 
is warrantable under such circumstances. Furthi 
more, the lamellar variety of cataract, even in its e 
treme degree of development, still permits a certa 
amount of light to enter the interior of the eye. ' 
therefore, an iridectomy is performed on an eye affei 
ed with an incomplete opacity of the cornea or lei 
the retina receives light not only through the new 
made aperture, but through the old pupil. The fa 
lire of the opacity to prevent the transmission of lig 
through the original pupil is a source of disturban 
to the eye as an optical apparatus, because in the ej 
as in the camera obscura, clearly defined images a 
only produced when all irregularly refracted rays a 
excluded. When diffused light is thrown over t 
retinal image, the latter becomes indistinct. For t 
foregoing reasons, the performance of iridectom 
under the circumstances above mentioned, does n 



ETIOLOGY. 33 

enable the eye to see well ; for not only does diffused 
light continue to reach the retina, but the dazzling 
sensation caused by too brilliant illumination of the 
field of vision is aggravated by the operation, inas- 
much as the pupil is thereby not only deprived of its 
contractile power, but its area is greatly enlarged. 

On account of the excessive size of the pupil, its loss 
of reactionary power, and the disturbance of the re- 
tinal image by diffused light, which follow iridectomy, 
an attempt was made to obviate these evils by substi- 
tuting the operation called iridodesis, in performing 
which a small incision is made in the cornea, close to 
the sclerotica, and the peripheral portion of the iris 
seized and drawn out of the wound, with such precau- 
tions that the entire pupillary border is left within the 
anterior chamber. A loop of thread is afterward tied 
around the prolapsed iris, to prevent it from slipping 
back into the eye ; the strangulated piece then rapidly 
necroses, falls off with the thread, and the wound is 
soon healed. The pupil has thus been transformed 
into an oval or longitudinal opening, and moved in 
toto toward the place of incision, the portion of the 
iris directly opposite the place of incision having been 
stretched to permit of the dislocation. The displaced 
pupil, with its constrictor pupillse intact and its reac- 
tionary function unimpaired, covers a scarcely greater 
area than it did before the operation. Moreover, a 

portion of the iris is interposed, as a diaphragm, he- 
2* 



34: SYMPATHETIC DISEASES OE THE EYE. 

hind the semi-opaque corneal spot, or in front of the 
partly translucent cataract, thereby protecting the re- 
tina from diffused rays of light ; so that, barring the 
sacrifice of some trueness of the corneal curvature (an 
evil which Pagenstecher sought to avoid by removing 
the incision into the verge of the sclerotica), we now 
have an eye which, although not projecting an abso- 
lutely perfect image upon the retina, certainly pos- 
sesses better vision than it would have, had an iridec- 
tomy been performed. 

"Wecker practises iridodesis in those cases in which 
the lens, from whatever cause, has become dislocated, 
so that its centre no longer corresponds to the centre 
of the pupil, or, more strictly speaking, to the axis of 
vision. If, for example, the zonula has been torn at 
its lower and inner insertion, the lens is displaced up- 
ward and outward, so that the space thus left between 
the lower internal border of the lens and the adjacent 
ciliary processes is partly visible through the pupil 
when dilated with atropia, or even when of normal 
size. Two images of an object, seen with such au eye, 
are thus projected upon the retina : one of them by 
the cornea, aqueous humor, lens, and vitreous humor ; 
and the other, by a refractive system from which the 
lens is absent. If the image made without the aid of 
the lens be, for any reason, the more useful of the two, 
the operation of iridodesis enables us to transfer the 
pupil permanently to a part of the cornea behind 



ETIOLOGY. 35 

which the lens is absent, whilst, by the same proce- 
dure, the iris on the opposite side is stretched over the 
dislocated lens, so as to cut off the second image, which 
would otherwise interfere with distinct vision. 

Iridodesis was at first regarded as a perfectly safe 
operation. But, in 1863, Alfred Graefe published the 
following significant case, in which iridodesis was per- 
formed on the eyes of a workman, aged twenty-three. 
Both eyes of the patient were affected with lamellar 
cataract, which, however, still permitted him to read 
No. 3 of Jaeger's test-types. Vision was improved im- 
mediately after the operation ; but eight weeks later 
Graefe found the man blind in both eyes, with occlu- 
sion of the pupils, in consequence of irido-cyclitis. 
The eyes, however, were not soft. The patient could 
see well with both eyes during the first week, at the 
end of which time, without any apparent cause, the 
sight diminished, first in one eye, and very soon there- 
after in the other, until it was reduced, at the time of 
the examination, to a merely quantitative perception of 
light. The exciting cause of the irido-cyclitis, in each 
eye, was attributed by Graefe to the stretching of the 
iris, incident to the iridodesis. Did not, however, sym- 
pathetic inflammation play its role in this case ? It is 
possible that the operation had directly excited irido- 
cyclitis in one eye only, and the inflammation had ex- 
tended sympathetically to the other, so that the same 
lesions would have appeared in the second eye even if it 



36 SYMPATHETIC DISEASES OE THE EYE. 

had not undergone the operation. Although the nearly 
simultaneous involvement of the two eyes, in Graefe's 
case, makes the latter opinion less trustworthy, never- 
theless, as we know from experience that irido-cyclitis 
is prone to be followed by sympathetic disease, and as 
Graefe established the existence of irido-cyclitis de- 
pending on the iridodesis, it must be admitted that this 
operation is not devoid of both primary and sympa- 
thetic danger. In fact, soon after Graefe's case came 
to light, one was reported by Steffan (1864), in which 
a girl aged nineteen, who had undergone iridodesis in 
one eye only, was affected, five weeks after the opera- 
tion, with irido-cyclitis in botli eyes. The disease may 
have first appeared in the wounded eye so insidiously 
as to receive no attention ; but it was not until the 
affection had, some weeks later, extended to the hith- 
erto perfectly sound eye, that the patient applied for 
relief. 

When, during a visit to London in 1864, I men- 
tioned to Critchett that the unfortunate cases of 
Graefe and Steffan had produced a want of confidence 
in iridodesis, among German oculists, he was not a lit- 
tle surprised at the two failures, as he had never en- 
countered like results in his very large personal expe- 
rience with the operation. My own operations have, 
likewise, been successful. But, on the other hand, 
unsuccessful cases and unfavorable criticisms of irido- 
desis have been sufficiently frequent in ophthalmolo- 



ETIOLOGY. 37 

gical literature, since 1864, to place the operation where 
it now remains — in discredit. 

Of far greater importance than iridodesis, as regards 
the danger of exciting inflammation, which may be 
propagated sympathetically to the second eye, are the 
operations for the relief of cataract. 

One of the fundamental methods of operating for 
this disease, that of depression or reclination, by which 
a hard cataract is forcibly thrust away from the axis 
of the visual rays into the vitreous body, is now almost 
totally abandoned on account of the destructive con- 
sequences that ensue, not only in the operated eye, 
but, secondarily, in its fellow. The displaced lens 
often plays the part of a foreign body — resting, it may 
be, in disagreeable contact with the ciliary body and 
choroid. It may thus lead to inflammation of, the 
uveal tract, if, indeed, this condition has not already 
been set up by the operation itself. The bad repute 
into which reclination has fallen is, however, due rather 
to the danger incurred by the eye undergoing opera- 
tion than to an appreciation of the sympathetic dis- 
turbances that may subsequently develop. 

Nor are the two operations of division and extrac- 
tion, so extensively employed in our days, wholly de" 
void of analogous risks. The object of division or 
discission of a cataract is to lacerate the anterior cap- 
sule and break up the substance of the lens, so that the 
latter shall come into contact with the aqueous humor. 



38 SYMPATHETIC DISEASES OF THE EYE. 

If the lens be only partially opaque, as in lamellar 
cataract, it becomes wholly so soon after exposure to 
the aqueous, and its fragments are gradually dissolved 
and absorbed until the cataract disappears. It some- 
times happens, either when proper precautions have 
not been taken during the operation, or in spite of 
them, that the lenticular fragments imbibe a great deal 
of aqueous humor, swell considerably, press upon the 
iris, and cause severe iritis, followed rapidly by cycli- 
tis and possibly by sympathetic disturbances. Al- 
though division is regarded by oculists as a very im- 
perfect surgical procedure, there are, nevertheless, a 
few forms of cataract to which no other is so well 
adapted. Among these are the lamellar cataract and 
the extremely rare variety called stationary nuclear 
cataract, in both of which the transparent periphery 
of the lens adheres so intimately to the capsule that it 
cannot be removed by the extraction method, with sat- 
isfactory results. 

Extraction by the flap operation, and v. Graefe's 
method of modified^ linear extraction, are the two 
most important of the different surgical operations 
for the removal of cataract. In operating by the first- 
named method, a semicircular flap, involving the whole 
upper half of the cornea^ is made by incising the lat- 
ter close to its scleral border. A large, patulous wound 
is thus produced, through which the lens is evacuated 
by gentle compression of the globe. In v. Graefe's 



ETIOLOGY. 39 

method of modified linear extraction the peculiarity 
of the incision is that it lies entirely in the sclerotica, 
and does not form a flap, its only curve being that of 
the eyeball itself. The incision is from ten to twelve 
millimetres long — its middle point lying at the topmost 
point of the corneal margin. Through this incision 
the lens is removed, after a preliminary iridectomy 
and laceration of the anterior capsule. The operations 
now most in vogue are a sort of compromise between 
the old flap operation, and the genuine peripheral lin- 
ear extraction as modified by v. Graefe. 

When the old method of removing the opaque lens 
by the flap operation was generally practised, very 
little was said of sympathetic ophthalmia after op- 
erations for cataract. Now and then we heard of 
irido-cyclitis and sympathetic affections, after the op- 
eration, and, in fact, a few such cases are matters of 
record ; but we undoubtedly hear much more of sym- 
pathetic disturbances in connection with operations 
for cataract, since the era of linear extraction. 

In all probability the first enucleation of an eyeball, 
upon which the method of linear extraction had been 
practised, was one that I performed in 1867, on ac- 
count of sympathetic ophthalmia of the other eye. A 
cataractous lens had been removed with complete suc- 
cess, by the flap operation, in 1865, from the loft eye 
of a man fifty years old. One year later Jaeger op- 
erated on the right eye by a linear method (the curved- 



40 SYMPATHETIC DISEASES OF THE EYE. 

lance section). Although the operation was skilfully 
performed, without any prolapse of the vitreous hu- 
mor, irido-cyclitis set in, and was followed by atrophy 
of the eyeball. Thirteen months after the second op- 
eration the patient again applied for relief, the atro- 
phic eye having never become quiescent, and being 
still affected with pain and photopsies. Six weeks 
prior to his reappearance pain commenced in the left 
temple, and, later, invaded the whole side of the head, 
undergoing exacerbations and remissions, but never 
complete suspension. Along with these symptoms, 
the vision of the left eye (which, as the patient declared, 
had been better, with the aid of cataract-glasses, since 
the first operation, than ever before) became impaired, 
and, at the date of examination, was reduced to one- 
fourteenth of normal, whilst the whole field of vision 
was obscured by a thick mist. The tension of the left 
eye was natural ; both cornea and iris were of healthy 
appearance; but the vitreous humor, when illuminated 
by the ophthalmoscope, was seen to be turbid through- 
out. After enucleation of the right eyeball, the 
sympathetic symptoms and the ophthalmoscopic ap- 
pearances gradually improved ; but no amendment of 
vision had taken place at the time of the patient's dis- 
charge, nine weeks after the operation. In the enu- 
cleated eye the anterior portion of the choroid, with 
the neighboring part of the ciliary muscle, could be 
easily detached from the sclerotica, whilst the connec- 



ETIOLOGY. 41 

tion between the retina and the vitreous body was 
likewise abnormal. In this unfortunate case the ex- 
traction of a cataract from the second eye had not only 
failed of its immediate object, but had seriously en- 
dangered the restored sight of the first eye. 

Knapp reported a similar unfortunate case in 1869. 
He operated successfully, after v. Graefe's method, on 
the left eye of a man sixty years of age. The eye 
healed in a favorable manner, and, six days after the 
first extraction, the operation was repeated upon the 
other eye. The repetition, however, was less fortu- 
nate. " There was haemorrhage into the anterior cham- 
ber, with subsequent iritis, and, later, sympathetic iritis 
of the first eye. Six weeks after the operation, both 
pupils had become occluded, and both eyeballs some- 
what soft. 

When the subject of sympathetic ophthalmia, occur- 
ring after cataract operations, was introduced by Klein, 
at the Heidelberg Ophthalmological Congress in 1874, 
a whole series of cases, wherein sympathetic affections 
had proceeded from the linear, or the various modifi- 
cations of the linear, extraction, were communicated 
by oculists present. Becker collected (1875) twenty- 
two cases (neglecting, however, to include Knapp's 
case) of sympathetic disease, resulting after cataract 
operations. Seven of these cases followed the flap op- 
eration, four of the latter being well-recognized speci- 
mens of simple senile cataract ; and fifteen occurred 



42 SYMPATHETIC DISEASES OF THE EYE. 

after operations by the linear method. Since that 
time further reports have been made of eases of sym- 
pathetic disease resulting from v. Graefe's extraction 
method. 

The various causes of the original irritation in an eye 
that has been subjected to an operation for cataract 
are : incarceration of the iris in the wound, with or 
without visible prolapse of the iris (Klein, v. Arlt) ; 
imprisonment in the wound of a portion of the capsule 
of the lens, so that the suspensory ligament and ciliary 
body, at the opposite side of the eye, are dragged upon, 
or detachment of the ciliary body at the same» spot 
(Horner) ; shrivelling of the capsule of the lens (caused 
by inflammatory exudation, or the development of a 
secondary cataract), with subsequent stretching of the 
iris and ciliary body (Hanel, Becker) ; and lastly, di- 
rect injury of the ciliary body, when the incision has 
been made too far out in the sclerotica (Ed. Meyer). 

Shall we include simple iridectomy among the 
surgical operations that may cause sympathetic oph- 
thalmia? Individual cases, showing this origin, are on 
record. 

We have, so far, seen how traumatic affections of the 
uveal tract may endanger the integrity of the unin- 
jured eye, and it is now time for us to inquire what 
importance those affections of the same regions, which 
are not due to injuries, may have in the production of 
sympathetic phenomena. The affections not due to 



ETIOLOGY. 43 

injury are divisible into two classes : the one embracing 
diseases excited by mechanical irritation of some por- 
tion of the uveal tract by bodies which cannot, strictly 
speaking, be designated as traumatic agents ; and the 
other, comprising the purely idiopathic affections. 

In the first class belong those lesions which are pro- 
duced by spontaneous dislocations of the lens, as well 
as by cysts of the iris, choroidal sarcomata, retinal gli- 
omata, and intra-ocular cysticerci. Mooren believes 
that irido-choroiditis is produced by a spontaneously 
dislocated lens, only when the latter has fallen into 
the anterior chamber. Hulke, Knapp, and Nagel saw 
cases in which cysts of the iris had caused irido-choroi- 
ditis, with sympathetic irritation ; and moreover, impli- 
cation of the second eye, even where the first eye never 
became inflamed. An eye affected with choroidal sar- 
coma is prone to be succeeded by sympathetic disease 
(Pagenstecher, Norris, Steffan, Nettleship, Salvioli, 
Hirschberg, Knies) ; but it should be borne in mind 
that choroidal sarcoma is very frequently due to a 
traumatic agency. Steiuheim reports a case of sym- 
pathetic irido-choroiditis ensuing upon traumatic gli- 
oma of the retina. The cysticerci are analogous to the 
neoplasms, in their causal relations to primary irido- 
choroiditis and its sympathetic sequelae. 

Idiopathic cyclitis, or irido-cyclitis, is a rare disease. 
When its attacks upon the two eyes are not synchro- 
nous, but are separated by a certain interval, it is not 



44 SYMPATHETIC DISEASES OF THE EYE. 

always easy to determine whether the second eye is 
sympathetically affected, or the disease in both eyes 
is due to a common cause. The same may be said of 
irido-choroiditis occasioned by the syphilitic poison, 
inasmuch as the disease of the second eye may be 
a sympathetic, and not a syphilitic lesion. When 
attacks of that variety of irido-choroiditis, which 
sometimes attends cerebrospinal meningitis, occur 
simultaneously in both eyes, the operation of a com- 
mon cause is evident ; bat if, on the other hand, 
one eye is first destroyed, and, later in the disease of 
the nervous system, the other is attacked in a similar 
way, it is probable that sympathetic influences have 
been at work. Noyes has reported a curious case of 
herpes zoster ophthalmicus of the left eye (that variety 
of herpes zoster in which the eruption follows the dis- 
tribution of the chief cutaneous branches of the trige- 
minal nerve), in consequence of which both eyes were 
destroyed by subsequent irido-choroiditis, beginning in 
the right eye ten months later than in the left, and 
without herpetic disease of the former. Jeffries, like- 
wise, saw a case of temporary sympathetic disturbance 
transplanted from an eye that had been destroyed by 
the same variety of herpes zoster. 

If prolapse, or incarceration of the iris or ciliary 
body, within a traumatic opening of the eyeball, near 
the corneal margin, may provoke irritation of the 
uveal tract and sympathetic phenomena, it is easy to 



ETIOLOGY. 45 

understand how the same effect may be produced 
when one or other of these structures is prolapsed or 
incarcerated within a similarly situated opening, made 
in the eye by an ulcerative process. In the latter con- 
dition very much the same relation of parts exists as 
after iridodesis ; and indeed, this sort of natural dis- 
placement of the pupil is quite frequent. But we 
must guard ourselves against an exaggerated concep- 
tion of the danger involved in the accident. I cannot 
recollect a case, in my personal experience, in which I 
have seen serious results to the second eye ensue upon 
this kind of cicatrization of the iris, even of its periph- 
eral portion, in the cornea. 

Where the ciliary body is thus imprisoned, a much 
more encouraging prognosis can be made than after a 
traumatic injury, inasmuch as the latter very fre- 
quently superadds a direct wound of the ciliary body. 
The danger of sympathetic inflammation is further di- 
minished when the ulcerated perforation of the cornea 
is very large, so that, instead of a small strangulation, 
a great part of the iris protrudes through the cornea, 
becomes indurated and thickened from exposure, and 
forms a permanent protuberance (staphyloma) through- 
out the area of the absent cornea. In the same way, 
severe chronic inflammatory processes in the eye may 
cause the sclerotic zone, just putside the margin of the 
cornea, to hecome relaxed and softened, so that the in 
tra-ocular pressure pushes it forward in such a manner 



46 SYMPATHETIC DI6EASES 0E THE EYE. 

as to present a series of small staphylomata, surround- 
ing a greater or less arc of the corneal periphery, and 
in some cases even its whole circumference. If, under 
such circumstances, sympathetic symptoms should de- 
clare themselves, they must be attributed, not so much 
to direct stretching and laceration of the ciliary body, 
as to a defect in the suspensory ligament, somewhere 
around the equator of the lens, permitting the disloca- 
tion of the latter, and the consequent development of 
sympathetic phenomena in the manner before de- 
scribed (page 30). 

So far as we have at present proceeded, it has ap- 
peared that the inflammatory lesions of the uveal tract 
threaten most danger to the second eye. None of the 
forms of uveal inflammation here brought under no- 
tice have followed a turbulent course, nor have they 
been attended with any acute purulent process. Their 
character has been insidious, and the ciliary body has 
been always more or less directly involved. 

Glaucoma, simply as such, possesses no inherent 
power to awaken sympathetic disease. When, how- 
ever, in the last stages of glaucoma, cyclo-choroiditis 
sets in, and the eye, hitherto abnormally hard, becomes 
soft, as well as painful over the ciliary region, the sec- 
ond eye becomes as much endangered sympathetically 
(Mooren, v. Arlt) as if the cyclo-choroiditis had its 
seat in a non-glaucomatous eye. Moreover, when, we 
see a case of sympathetic ophthalmia ascribed to a de- 



ETIOLOGY. 47 

tachment of the retina in the first eye, or to a haem- 
orrhage into the vitreous humor, we should incline 
toward the belief that a cyclitis had supervened upon 
the primary lesion, and had itself been the cause of 
the sympathetic derangement; as Mooren expressly 
argues, in the case of retinal detachment. 

Some important questions which we next have to 
answer are : Does 'purulent inflammation of the 
uveal tract, also, lead to sympathetic ophthalmia ? 
Can sympathetic ophthalmia supervene when the dis- 
ease of the first eye is confined to the iris or to the 
choroid alone, produces no tenderness over the ciliary 
region, does not implicate the ciliary body, and pur- 
sues an unobtrusive course ? Finally, can sympathetic 
ophthalmia be set on foot without lesion of any part 
whatever of the uveal tract of the first eye ? 

It has been generally held that acute purulent in- 
flammation of the uveal tract (better termed panoph- 
thalmitis, inasmuch as the purulent process, accompa- 
•nied by great swelling, is not confined to the uveal 
tract, but attacks all the tunics of the eye, as well as 
the vitreous humor) is devoid of sympathetic danger to 
the second eye. But exceptional cases to the contrary 
have been reported (Mooren, Rossander). Alt, who 
ascertained the pathological histories of one hundred 
and ten eyes, which had been enucleated on account 
of sympathetic disease (thirty-two of them under his 
own observation), found that twenty-one of the num- 



48 SYMPATHETIC DISEASES OF THE EYE. 

ber, or nineteen per cent., had been affected with typi- 
cal panophthalmitis. 

Again, it has been established that sympathetic af- 
fections may occur independently of any disease of 
the ciliary body, and even without any well-defined 
lesion of the uveal tract. Mooren (1869) cites among 
the diseases which may lead to sympathetic trouble, 
not only lesions of the ciliary body, but also those of 
the con j unctiva, sclerotica, cornea, iris, choroid, retina, 
and lastly, atrophy of the globe. It should be added, 
however, that he gives the most etiological importance 
to cyclitis, and lays particular stress upon the stretch- 
ing, or laceration of the ciliary body, whereby a sim- 
ple, minute prolapse of the iris becomes fraught with 
danger to the second eye. Peppmliller (1871) re- 
ported a few cases of sympathetic iritis following 
simple prolapse of the iris, without symptoms of 
cyclitis. Liiders (1872) saw a case of injury of the 
eye, in which the iris and anterior capsule of the lens, 
in the second eye, became agglutinated together seven 
weeks after the injury, although there had been no 
sensitiveness to pressure or softening of the injured 
eye. 

From a series of cases brought forward by Warlo- 
mont (1872), it appeared, in one case, that an obstinate 
sympathetic keratoconjunctivitis could only be cured 
after enucleation of the first eye, which had been for 
a long time atrophied, but never sensitive. In another 



ETIOLOGY. 49 

case, that of a veteran, Warlomont speaks of a " severe 
external inflammation of the right eye " as an expres- 
sion of sympathetic disease, although the stump of the 
other eye, which had been destroyed by a wound, was 
" perfectly painless." Other cases of the series give 
abundant evidence that phthisical eyeballs, which have 
never manifested pain, either spontaneously or on 
pressure, can, nevertheless, set up sympathetic disease. 
Out of ninety cases of sympathetic ophthalmia, pub- 
lished by Rossander in 1876, two originated in pain- 
less atrophy of the fellow eye ; and out of ninety sim- 
ilar cases, reported by Vignaux in 1877, eight could 
be clearly referred to the same condition. The state- 
ment, therefore, is not entirely warrantable, that when 
a phthisical eye has seemed perfectly quiescent, a de- 
posit of bone within the degenerated globe, irritating 
the choroidal tract in a purely mechanical way, and 
thereby renewing the tenderness and pain in the atro- 
phic eye, must invariably be present in order to pro- 
duce sympathetic disease. 

Cohn (1871) met with two cases of sympathetic im- 
pairment of vision, after gunshot wounds, without 
symptoms of iritis, or cyclitis, in the wounded eye. In 
one of his cases the blind and offending eye had un- 
dergone extensive inflammation of the choroid and 
retina, as was established both by the ophthalmoscope 
and by anatomical examination after enucleation. la 

the other case, only a superficial grazing wound from 
3 



50 SYMPATHETIC DISEASES OF THE EVE. 

a fragment of shell, had been inflicted upon the eye, 
which showed no internal lesion other than an effusion 
of blood between the yellow spot of the retina and the 
choroid. Brecht (1874) also saw a case in which dis- 
turbance of sight in the right eye had been transmitted 
sympathetically from its injured fellow, which latter, 
however, was " absolutely quiescent, showed no trace 
of unnatural redness, and was wholly devoid of pain, 
either spontaneously or under pressure." Pfluger 
(1875) traced a sympathetic affection of the one eye 
to a wound made by a piece of stone on the other, 
whilst the ciliary body of the injured organ seemed to 
be normal in every respect. He also reported another 
case, at the same time, in which an eye that had been 
destroyed by gonorrhceal ophthalmia, proved treacher- 
ous to its mate a few weeks later ; nevertheless, when 
enucleated, it showed no sign of cyclitis, but simply 
an inflammatory infiltration of the iris. 

Indeed, if we give credence to general pathologico- 
anatomical reports, we shall not need to search out 
individual cases in order to prove that sympathetic 
affections of the eye may arise quite independently of 
any disease of the ciliary body. Out of one hundred 
and ten dissected eyes upon which Alt reported, m 
the "ArcMv fur Augen- und OhrenheilTcunde, 1877," 
only seventy-six and one-half per cent, disclosed any 
disease of the ciliary body. Alt's words are as fol- 
lows: "The iris is altered in sixty-eight per cent., and 



ETIOLOGY. 51 

the choroid in seventy-three per cent- of the cases ; so 
that the alterations found in the individual parts of 
the uveal tract are about equally distributed — those 
in the ciliary body very slightly exceeding in number 
those in each of the other parts." 

The fitting of an artificial eye upon a painless stump 
has been known to develop sympathetic ophthalmia 
(Lawson, Mooren, Keyser) ; and reports of cases are at 
hand where the insertion of an artificial eye into an 
orbit, from which a diseased eye had been removed to 
abolish sympathetic irritation, has again excited the 
same morbid condition (Salomon, Warlomout). Fi- 
nally, it has happened that the enucleation of an in- 
jured eye, or the sequelae of the operation, performed 
for the especial purpose of preventing the sympathetic 
implication of its partner, have produced the appre- 
hended condition (Mooren, Colsmann); or that the 
amelioration first following the enucleation of the 
offending eye has afterward disappeared, and the 
sympathetic disturbance been reinstated by the agency 
of the surgical operation itself (Hasket Derby). 

While it is already evident, from our superficial 
notice of facts, which will receive further considera- 
tion as we proceed, that manifold forms of sympathetic 
disease may arise without the presence of cyclitis at 
the time, or even without disease of any portion of the 
uveal tract, there remains a question which should be 
answered in this place. Assuming that an injured 



52 SYMPATHETIC DISEASES OF THE EYE. 

eye, in which no foreign body lies concealed, recover 
perfectly y so far as we can ascertain by clinical exam 
ination, from an attack of severe cyclitis — recover 
even without degenerating into a state of atrophy- 
can such an eye, nevertheless, excite symptoms of sym 
pathetic ophthalmia in the fellow eye ? This question 
be it understood, can only be put where the cyclitis i 
of traumatic origin / for if, after the recovery of ai 
eye from spontaneous cyclitis, the same disease be se 
up in the second eye, we cannot have absolute proo 
of its sympathetic character. In answer to the fore 
going question, I communicate the following case : 

A common laborer, sixty years of age, presentee 
himself at the Ophthalmic Clinic, October 3, 1875 
He stated that he had been struck on the right eye 
five years previously, by the rebounding branch of : 
tree, and that the sight of the injured eye had beei 
instantaneously lost. He also complained that fo 
about five years preceding his appearance he had beei 
unable to read with his left eye, and that during tb 
last year the sight of this eye had rapidly decreased 
Both eyes showed signs of cataract. In the total! 
opaque lens of the right eye sparkling crystals of chc 
lesterine, the product of a prolonged process of deger 
eration, justified the inference that the cataract hai 
existed even a considerable period previously to th 
infliction of the injury. In the left eye the catarac 
was of more recent formation. In each eye the pej 



ETIOLOGY. 53 

ception of light corresponded to the degree of opacity 
of the lens. Both cataracts were extracted at one 
sitting, by v. Grraefe's methodj but both operations met 
with impediments to their perfect performance. In 
the right eye fragments of the lens remained behind 
in the capsule, and after the removal of the speculum 
the patient squeezed his lids together, causing escape of 
vitreous through the incision. In the left eye vitreous 
humor escaped before the extraction of the lens, so 
that the latter had to be removed with the spoon. The 
right eye recovered with but slight inflammatory re- 
action ; the left, however, developed irido-cyclitis. Of 
the latter (left) organ, it was noted, on October 3d : 
" Cornea and aqueous cloudy ; pupil occluded by ex- 
udation masses, and displaced upward ; ciliary region 
painful ; abnormal softness of the globe ; perception 
of light." And again, on November 22d : " Tension 
of eye has become normal ; the ciliary region is but 
slightly sensitive to the touch ; a small opening has been 
cleared through the upper and outer part of the pupil ; 
the patient can count fingers, with this eye, at a dis- 
tance of three feet." On the day of the patient's dis- 
charge, December 1st, no vestige of irritation, sensi- 
tiveness, or softness remained in the left eye ; the 
cyclitis had completely vanished, and vision was ^ 
normal. In the right eye the pupil was clear, and the 
fundus of the globe distinctly visible, but floating 
opacities in the vitreous were scattered over the field 



54: SYMPATHETIC DISEASES OF THE EYE. . 

of vision. These opacities, however, could not be 
taken as evidence of cyclitis, because the ciliary body 
in the right eye had not been painful, and the eyeball, 
after the week first following the operation, had been 
perfectly free from injection, painless, and of normal 
tension. It possessed one-eighth of the normal amount 
of vision. No portion of the iris, in either eye, was 
included in the cicatrix. The patient was discharged 
in the forementioned condition. 

On January 18, 1876, he returned, with the com- 
plaint that, without any external provocation, his right 
eye now suffered. The left eye — the one that had 
been affected with cyclitis — had not been in the least 
degree painful or reddened during the seven weeks 
succeeding the discharge of the patient, and on the 
day of his return showed no trace at all of vascular 
injection, or of tenderness, on pressure, over the ciliary 
body ; its vision was normal. The right eye, on the 
other hand, showed all the symptoms of a highly acute 
irido-cyclitis : intense episcleral injection environed 
the corneal border, the pupil was plugged with a 
mass of pus, and displaced .toward the place of inci- 
sion, the globe was soft, the sight was dwindled to a 
mere perception of light and darkness, and the al- 
ready spontaneously acute pain became maddening 
when pressure was made over the ciliary body. 

Here an operation, performed for the relief of cata- 
ract, had excited primary cyclitis in the left eye. The 



ETIOLOGY. 55 

disease, however, had not advanced to atrophy of the 
globe, but recovered most perfectly. About six weeks 
later, after all the symptoms of the previous cyelitis 
had disappeared from the left eye, the right eye, with- 
out any external cause, and without any symptoms of 
the reappearance of disease in the eye originally af- 
fected, was visited with an attack of irido-cyclitis, 
greatly surpassing in severity the primary affection of 
the first eye. Thus, even after the complete recovery 
of one eye from an attack of cyelitis — a recovery not 
ending in atrophy of the globe — the other eye is not 
thereby absolutely assured of immunity against an 
outbreak of sympathetic ophthalmia. 



SECTION III. 



PATHOLOGY. 

In the preceding section we have considered, so far 
as is practicable in the preliminary stage of our work, 
the various individual lesions from which originate the 
sympathetic diseases usually grouped under the name 
of sympathetic ophthalmia. We now pass to a more 
accurate description of the manifold forms in which 
sympathetic ophthalmia appears. The more knowl- 
edge we acquire of this class of affections the more 
multiplied they become. Many forms of ophthalmic 
disease, whose sympathetic character was formerly 
and even but recently denied, are now permanently 
settled in the category of the sympathetic affections ; 
and many others, which are still involved in great 
doubt, and whose acceptance as sympathetic diseases 
.is properly deferred, may hereafter come to be re- 
garded as integral links in this dangerous chain of 
maladies. 

The following list comprises the sympathetic dis- 
eases of the eye : neuralgia of the ciliary nerves ; irri- 



PATHOLOGY. 57 

tation of the retina, and of the optic nerve ; functional 
disturbance of the retina ; inflammation, severally, of 
the conjunctiva, cornea, and choroid; inflammation of 
the uveal tract, with or without participation on the 
part of the ciliary body, so that there may be both a 
sympathetic iritis and a sympathetic choroiditis, with- 
out coexisting cyclitis; inflammation of the retina, 
alone or in conjunction with inflammation of the cho- 
roid ; inflammation of the optic nerve ; glaucoma ; 
disease of the vitreous, and of the lens. "Whether all 
the diseases above enumerated are legitimate occu- 
pants of the list of sympathetic affections or not, we 
shall see in the sequel. We will first describe the 
symptoms of sympathetic irritation. 

The ciliary nerves play so important roles in the 
pathogeny of the sympathetic diseases that, before dis- 
cussing the subject of ciliary neuralgia, we shall de- 
vote a few lines to the anatomical description of these 
nerves. 

The naso-ciliary nerve enters the orbit through the 
sphenoidal fissure, as the third branch of the ophthal- 
mic (sensitive) division of the trigeminus. In the first 
part of its course it lies on the temporal side of the 
optic nerve and then passes obliquely over toward the 
inner wall of the orbit, between the optic nerve and 
the superior rectus muscle. As it crosses the optic 
nerve, the naso-ciliaris, having previously given off the 

long sensory root (radix longa) to the ciliary ganglion, 
3* 



58 SYMPATHETIC DISEASES OF THE EYE. 

sends off from one to three filaments, called the long 
ciliary nerves, which run straight forward to the eye- 
ball. The ciliary ganglion, an oblong flattened body, 
of about the size of a pin-head, situated between the 
optic nerve and the external rectus muscle, receives 
motor fibres (radix brevis) from the third cranial 
nerve (oculo-motor), and sympathetic fibres (radix 
sympathetica) from the cavernous plexus, which sur- 
rounds the internal carotid artery. The three roots 
just mentioned enter the posterior border of the gan- 
glion ; whilst the anterior border gives off the short 
ciliary nerves, which then pass forward to enter the 
eye. The long and short ciliary nerves split up into 
fifteen or twenty filaments before piercing the sclero- 
tica around the periphery of the optic nerve, and di- 
viding still further as they advance, run forward, be- 
tween the choroid and sclerotica, to the ciliary muscle, 
in which they form a fine net-work, from which nu- 
merous fibres are distributed to the iris and cornea. 
The ciliary nerves, by reason of their triple composi- 
tion, confer sensibility upon the individual parts of the 
eye, as well as motility upon the ciliary muscle, the 
muscles of the iris, and those of the parietes of the 
vessels. They are, moreover, probably endowed with 
other functions, which will engage our attention far- 
ther on. 

In connection with the phenomena of sympathetic 
irritation, it should be remembered that, when one eye 



PATHOLOGY. 59 

becomes inflamed and painful, from whatever cause, 
the other can no longer, as a general rule, be used 
without showing unmistakable symptoms of weariness. 
In certain inflammations — for example, those phlycten- 
ular lesions of the cornea which accompany the so- 
called scrofulous affections of the eye — the photophobia 
of the diseased eye is often propagated to the second, 
even when the latter is perfectly well, so that both eyes 
are held tightly closed, and are totally incapacitated 
for use. Or, if the case does not exhibit such extreme 
symptoms as these, the second eye, in consequence of 
severe irritation, pain, or inflammation of the first, can- 
not be employed at fine work without soon becoming 
tired and strained. Every considerable effort, perhaps 
for a longer, perhaps for a shorter period, causes the 
second eye to redden and become irritable, and pro- 
vokes so painful sensations as seriously to impede 
its function. Indeed, the presence of a particle of 
coal-dust in the conjunctival sac of the one eye often- 
times suffices to set up a Whole train of symptoms of 
irritation in the other. 

I do not know exactly what name to give to this 
striking form of " fellow-suffering " (as it were " sym- 
pathy ") in the well eye. " Sympathetic irritation " is 
rather objectionable, for, although these words really 
define the state of things as just described, we feel 
justified in reserving this expression to indicate a con- 
dition which closely borders upon sympathetic ophthal- 



60 SYMPATHETIC DISEASES OF THE EYE. 

mia, or, indeed, constitutes its preliminary stage. For, 
while the irritation in the second eye, which is due to 
pain in the first, usually vanishes with the subsidence 
of the original pain, or very simple means, such as the 
application of a compress-bandage to the diseased eye, 
generally relieves the spasmodic closure of the lids in 
the other, and enables the patient to separate them 
freely, this simple form of irritation in the second eye 
— and here is the main point — may persist for a long 
time without danger of involving the organ in sub- 
stantial lesions. 

On the other hand, where true " sympathetic irrita- 
tion "is present, we have a very different and infi- 
nitely more serious state of matters. For example, an 
eye that has received an injury, and been very speedily 
attacked with irritation and inflammation, may excite 
almost simultaneously, in the opposite eye, so acute and 
painful phenomena that it is by no means uncommon 
to hear the patients complain that, for the first day or 
two after the injury, they rtere Mind in both eyes. 
When the inflammation and pain subsequently subside 
in the injured eye, the second becomes again quiescent 
and serviceable,, and remains so during a certain inter- 
val. After a time, however, without the necessity of 
any especial exacerbation of the disease in the first eye, 
and even when the eyeball is no longer spontaneously 
painful, but only painful or sensitive to the touch, the 
symptoms of irritation may reappear in the second eye, 



PATHOLOGY. 61 

so that it becomes sensitive when exposed to a brighter 
light than usual, and fatigued by work that makes but 
slight demands upon its accommodation. The patient, 
moreover, may occasionally have noticed, even from 
the date of the original injury, that the employment 
of the eye, at the accustomed distance from the work, 
required a certain effort, which was relieved by holding 
the work farther from the eye. If the exercise of vi- 
sion is persistently prolonged, the eye becomes bathed 
in tears, pain is felt, as well in the neighboring regions 
as in the eye itself, objects are seen as if through a fog, 
and if the work be pushed to an extreme limit, the eye 
becomes utterly disabled for a time. We can, further, 
often learn by inquiry, that the eye, even when not 
taxed by exertion, is subject to temporary obscuration 
of its field of vision. Sometimes, also, during this irri- 
tative stage, the patient complains of subjective sensa- 
tions of light, in the form of sparks or flashes of fire. 

It is not probable that these symptoms of " sympa- 
thetic irritation " depend, in their early stage, upon 
textural alteration already present in the eye, for they 
promptly disappear, once for all, as soon as the oppo- 
site eye is enucleated. In those cases in which the 
symptoms of irritation do not cease in the second eye, 
notwithstanding the enucleation of the injured eye, 
but, on the contrary, give place to those of violent in- 
flammation, or in which the inflammation is lit up in 
the sympathetic eye after the operation, without any 



62 SYMPATHETIC DISEASES OF THE EYE. 

preliminary stage of irritation, we must assume that 
some structural disease, without salient symptoms, 
had already invaded the second eye at the time when 
its partner was removed ; or that some insidious dis- 
ease, which did not depend directly upon the disease 
itself, was on its way toward the second eye, and could 
not be prevented by the operation ; or, finally, that the 
very operation, practised for the relief of the irritated 
eye, was itself the cause of the sympathetic oph- 
thalmia. 

If no textural alteration exists in the second eye at 
the time of the " sympathetic irritation," the latter 
must be ascribed to an irritated condition of the ciliary 
nerves, as well as of the retina and optic nerve. Under 
such circumstances, it appears to me that the primary 
involvement is to be sought for in the retina, inasmuch 
as the sensitiveness of the eye to light, the quick exhaus- 
tion of the retina by work, the transitory obscuration 
of the field of vision, and the subjective sensations of 
light, all point toward this conclusion. This primary 
irritation or hypersesthesia of the retina begets a sec- 
ondary or reflex neurosis in the tract of the ciliary 
nerves, which consist in great part of sensory filaments 
from the trigeminus. In consonance with this view, 
we do not believe that these symptoms depend upon a 
hidden affection of the muscles, or upon asthenopia of 
accommodation, such as appears in consequence of the 
weakness of the muscle concerned in this function. Nor 



PATHOLOGY. 63 

is it our opinion that the holding of the work at a far- 
ther distance than usual from the eye is so much a proof 
that the affection of the ciliary muscle is the primary 
one, from which the other phenomena of sympathetic 
irritation proceed, as that the ciliary nerves labor under 
a reflex neurosis propagated from the primary affec- 
tion of the retina, so that the contractions of the ciliary 
muscle, which necessarily provoke pain in the sensory 
filaments of the sympathetic nerves, are avoided so far 
as possible. 

It is certainly not our intention, in what we have just 
said, to deny that primary ciliary neuralgia may ini- 
tiate sympathetic disease. This affection, which has its 
seat in the ciliary and eircumorbital branches of the 
trigeminus, is characterized by violent pain, which is in- 
creased by work, so long as work is possible, as well as 
by light ; while, at the same time, the pain does not 
disappear, even if the patients abandon all exertion on 
the part of the eyes, and exclude them wholly from 
the influence of light. Although we cannot discover 
any definite lesion of the eye, it is evident that the 
neuralgia of the eyeball is principally located in the 
ciliary body (the very locality of the chief distribution 
of the nerves), because even the slightest pressure over 
the ciliary region exaggerates the pain to an intoler- 
able degree. To diagnosticate cyclitis under these 
circumstances would be quite unjustifiable, for not a 
trace of inflammation exists in the ciliary body a 



64 SYMPATHETIC DISEASES OF THE EYE. 

this period, but simply an exquisitely painful and vio- 
lent neuralgia of the region involved. 

The same irritative condition which has been wit- 
nessed in the tract of the ciliary nerves, may also as- 
sume a violent type in the retina and optic nerve; so 
that the symptoms of sympathetic irritation vary ac- 
cording to the functions of the parts involved. The 
eye affected by sympathy may exhibit the most intense 
photophobia, which, in turn, may develop spasmodic 
action of the orbicularis muscle, which now presses 
the eyelids so tightly together that the patient cannot 
open his eyes at all, and often imagines himself to be 
blind. Donders has related several cases of this form 
of severe sympathetic irritation. The fact that the 
photophobia disappears, and the. normal power of vi- 
.sion returns, after enucleation of the opposite eyeball, 
goes to prove that the spasm of the lids was due to the 
photophobia alone. We are here to remark, moreover, 
that the sympathetic irritation of the retina may de- 
generate not only into intense photophobia, but into 
the worst phase of photopsia, in which the patient is 
beset with subjective sensations of the most torment- 
ing character. "We have already mentioned that the 
patient may often suffer from transitory sensations of 
light during the ordinary forms of sympathetic irrita- 
tion ; but it sometimes happens that this phenomenon 
reaches an extraordinary height, and then constitutes 
an affection of the most serious importance. 



PATHOLOGY. 65 

An eyeball is wounded by a penetrating fragment of 
a percussion-cap. About one year afterward, Alfred 
Graefe enucleates the injured eye (although its vision 
is but slightly deteriorated), on account of the distress- 
ing subjective sensations in the other eye, which are, 
however, entirely independent of any demonstrable 
morbid alteration, while, furthermore, the vision of 
this eye is absolutely unimpaired. Leber examines 
the enucleated eye and discovers the fragment of cap 
adhering firmly to the inner surface of the apparently 
normal ciliary body. That portion of the retina which 
covers the ciliary body, and is called the pars ciliaris 
retinae, is thickened where it lies applied to the for- 
eign body, and a new formation of connective tissue 
is found at the intra-ooular extremity of the optic 
nerve. The subjective sensations are not ameliorated 
by the operation, but reach so extreme a grade 
that fears are entertained for the life of the patient. 
A violent degree of photopsia may certainly ac- 
company simple irritation of the optic nerve, but in 
that case the photopsies vanish after the enucleation 
of the first eye. Was there not, therefore, in this case 
of Graefe's, some substantial lesion already present in 
the sympathizing eye ? We shall resume this question 
in a subsequent place. 

But photophobia and photopsies are not the only 
subjective symptoms of irritation of the optic nerve 
and retina ; for the sympathy may express itself in the 



66 SYMPATHETIC DISEASES OF THE EYE. 

form of distinct functional disturbances, or marked 
impairment of vision, without our being able to dem- 
onstrate the presence of any definite structural lesion 
in either the percipient or the conducting apparatus 
of the eye. We should first mention, in connection 
with this form of sympathetic irritation, that we may 
observe not only momentary obscuration and limitation 
of the field of vision, but even longer intervals of sus- 
pension of the normal function of the retina. Lie- 
breich gives instances in which the sympathetic irrita- 
tion of the retina manifested itself by photophobia 
and obscurations of the field of vision, which lasted 
from half a minute to a minute, appearing and disap- 
pearing at regular rhythmical intervals. A still more 
important form is that sympathetic disturbance of vi- 
sion which bears some relation to the affection to 
which v. Graef e gave the name of anmsthesia of the 
retina (proceeding from hyperaesthesia), while Stef- 
f an did not hesitate to call it genuine hyperesthesia of 
the retina. This is the same malady for which Schil- 
ling proposed the name of " contraction of the field of 
vision, without anatomical lesion." This disease is 
characterized, on the one hand, by a diminution of the 
acuteness of central vision, and on the other by anaes- 
thesia of the peripheral portion of the retina, so that 
the field of vision is concentrically contracted, and in 
a very uniform manner in all directions. The func- 
tion of accommodation may also be impaired. The 



PATHOLOGY. 67 

ophthalmoscope reveals nothing abnormal, either in the 
retina or in the optic nerve. Mooren has reported 
several cases of this form of sympathetic disease, and 
a case described by Brecht (1874) may here serve for 
an example. 

The injured left eye is very soft at the time of the 
first examination, but is entirely free from irritation. 
"With the right eye, which appears normal, the patient 
can count fingers, in ordinary light, at a distance of 
only eight feet. If the eye is fixed upon a given point 
on a black-board nine inches away, it cannot distin- 
guish the traces of a piece of white chalk at a greater 
distance than two and a half inches in any direction 
from the point of fixation. The field of vision is, 
therefore, concentrically contracted, so that, at a dis- 
tance of nine inches from the eye, it embraces only 
a circle two and a half inches in diameter, described 
around the point of fixation. There are no pathologi- 
cal alterations visible with the ophthalmoscope. After 
enucleation of the left eyeball, both central and per- 
ipheral vision begin, to show a decided improvement, 
and ten weeks after the operation, central acuteness of 
vision, as well as the peripheral field of vision and the 
function of accommodation, are all nearly normal. A 
black splinter of metal is found imprisoned within the 
enucleated eyeball. 

Cohn has reported two cases which, as Leber be- 
lieves, should be included in the present class of sym- 



68 SYMPATHETIC DISEASES OF THE EYE. 

pathetic affections. "We have previously alluded to 
the pathological changes in eyes that have been sub- 
jected to contusions from gunshot wounds (page 49), 
so that we may here briefly state that the sympathetic 
disturbance of vision in Cohn's cases was character- 
ized by reduction of central vision, as well as by im- 
pairment of the function of accommodation, and, in 
one of the cases, by severe photopsies, which were re- 
peatedly produced by the most trivial exercise of the 
eye. Cohn says nothing about the state of the field of 
vision, so that we do not know whether it was con- 
tracted concentrically, if contracted at all. The enu- 
cleation of the injured eye completely dissipated the 
sympathetic troubles. Hypersesthes-ia of the retina 
(not necessarily accompanied by photophobia and pho- 
topsia) would appear to be the cause of similar sympa- 
thetic disturbances of vision without any structural 
alterations in the eye. 

We now turn our attention from the manifold as- 
pects of sympathetic irritation, to the still more varied 
forms of sympathetic inflammation. In what causal 
relationship with the inflammation does the irritation 
stand? Is sympathetic irritation the forerunner of 
sympathetic inflammation ? There is no doubt that 
the complex of symptoms, characterized by sensitive- 
ness of the eye to light and work, slight transitory 
congestion of the pericorneal region, painful sensa- 



PATHOLOGY. C9 

tions in and around the eye, and' periodical haziness of 
the field of vision, is to be regarded in the light of a 
premonitory stage of sympathetic inflammation, which 
now lies close at hand. It is, however, still an open 
question, whether the uncomplicated ciliary neurosis, 
or pure photophobia and photopsia, as well as func- 
tional disturbances of the retina without structural 
lesions (although these affections can, as a matter of 
fact, continue, simply as such, for a long time), do not 
finally become transformed, on the one hand into 
cyclitis, or on the other into inflammation of the retina 
or of the optic nerve. It would, however, be incur- 
ring a very bold risk to base our therapeutical meas- 
ures on the assumption that such a state of irritation 
never becomes transmuted into one of inflammation. 

In proceeding to consider the different manifesta- 
tions of sympathetic inflammation, as it affects the in- 
dividual parts of the eye, we must first notice the cornea. 
Symyithetic keratitis is described by "Warlomont as 
being marked by inflammatory cloudiness of the super- 
ficial layers of the cornea, and a profuse development 
of vessels therein, conjoined with pain in the periorbital 
region and head, on the affected side, together with in- 
tense monocular conjunctivitis. We have already re- 
ferred to a case in which an eye was destroyed by the 
thrust of a cow's horn. The eyeball was reduced to a 
small stump, and, for ten years afterward, remained 
painless and inoffensive to its mate. After that period 



70 SYMPATHETIC DISEASES OF THE EYE. 

keratitis appeared in the second eye, underwent con- 
tinual relapses during several years, and was rebellious 
to all treatment until the atrophic stump was finally 
enucleated, when the sympathetic affection disap- 
peared, as if by magic. In further proof of the 
sympathetic nature of the disease, it may be stated 
that an artificial eye, worn after the operation, excited 
inflammation of the palbebra'l conjunctiva, with which 
it came in contact, as well as a fresh outbreak of 
vascular keratitis in the remaining eye, and that when 
the artificial eye was thrown aside and poultices were 
applied to the inflamed cavity for several days, the 
sympathetic keratitis disappeared without the neces- 
sity of having recourse to any other treatment. 

Rossander has reported one case of sympathetic in- 
termittent keratitis ; while Gralezowski, Kheindorf, 
Ledoux and Vignaux have seen cases of sympathetic 
Jcerato-iritis. Vignaux (1877) observed the latter condi- 
tion eight times among ninety cases of sympathetic oph- 
thalmia. " In this form of keratitis," writes the last- 
named observer, "the cornea becomes the seat of a very 
diffuse (sometimes circumscribed) infiltration, which 
becomes transformed into superficial ulcerations : while 
one ulcer heals, another makes its appearance. The 
iris always becomes implicated in the inflammatory 
process, and pus is occasionally found in the anterior 
chamber. The ciliary pain is acute, and the photo- 
phobia is almost as excessive as that which we meet 



PATHOLOGY. 71 

with in scrofulous inflammation of the cornea." "We 
must especially notice that the ciliary body does not 
seem to be affected during these forms of inflamma- 
tion, which are generally milder than all others. Al- 
though not infrequently met with by French writers 
(constituting as they do almost ten per cent, of Vig- 
naux's series of cases), they are, nevertheless, seldom 
reported in German medical literature. Perhaps this 
hiatus has hitherto been due to a lack of vigilance in 
observation. 

Sympathetic ophthalmia may also manifest itself by a 
genuine attack of sclerotitis, unaccompanied by inflam- 
mation of the ciliary body. Rossander, for instance, 
mentions two such cases, in which sympathetic sclero- 
titis was happily relieved by the enucleation of the in- 
jured eye. 

Of the various sympathetic inflammatory processes 
that may affect the individual structures of the eye, 
those which primarily have their seat in the uveal 
tract vastly exceed all others in importance, and they 
are, further, the ones which most often come under 
observation and treatment. By reason, therefore, of 
their great significance and frequency, as well as their 
destructive effects, it is of the first moment that they 
should be promptly and accurately diagnosticated, with 
a view to their timely and appropriate treatment. 

Iritis serosa is the least severe of the different forms 
of sympathetic inflammation of the uveal tract. Sup- 



72 SYMPATHETIC DISEASES OF THE EYE. 

pose that the patient complains of a slight failure of 
vision in his well eye, whilst the opposite eye, which 
had, perchance, been destroyed by an injury, is still 
painful, or, perhaps, only sensitive to pressure. The 
characteristic symptoms of sympathetic irritation are 
not present : the worst that the patient complains of 
is, that for some time past every object has appeared 
to be covered with a thin cloud. If the medical at- 
tendant is not alert, the actual pathological process 
may be overlooked, and perhaps mistaken for a sym- 
pathetic functional disturbance of the retina. Careful 
investigation, however, by daylight, or by the oblique 
illumination of the eye (the image of a lamp-flame 
being projected upon the cornea by a strong convex 
lens), will reveal small, grayish, punctated opacities on 
the posterior surface of the lower half of the cornea, 
while, if the pupil be illuminated by the ophthalmo- 
scope (the patient looking downward), its area will 
appear to be filled, as it were, with fine dust, inter- 
spersed here and there with small, dark specks, vary- 
ing in size from a pin-head to almost microscopical 
minuteness. It may, indeed, happen that with the 
unaided eye, or even with oblique illumination, nothing 
unusual can at first be discovered, and that it will re- 
quire the use of the ophthalmoscope before the punc- 
tated appearance of the cornea can be accurately 
recognized by the incident light. We shall, moreover, 
now begin to notice that although the eye had been 



PATHOLOGY. 73 

pale before the examination, the irritation incident to 
this procedure has of itself sufficed to provoke a faint 
rosy zone of episcleral injection around the margin of 
the cornea. We shall also, perhaps, see that the pupil, 
although perfectly free, and nowhere adherent to the 
anterior capsule, does not react so promptly to the in- 
fluence of light and shade, as when in a normal con- 
dition, and that, although a comparison with the 
other eye may not now be practicable, the pupil is 
evidently rather larger, and the anterior chamber 
much deeper than in the mate. Sensitiveness of tha 
ciliary body is not necessarily educed by pressure. 
The tension of the globe is, on the whole, quite normal : 
sometimes it may be increased, but it is never dimin- 
ished. Such, then, are the most simple indications of 
serous iritis. 

We have already mentioned that the fine opacities 
in iritis serosa are situated on the posterior surface of 
the cornea. We assume that there is an increased ex- 
udation of serum (with the addition of pus-corpuscles 
and coagulable material) from the iris into the anterior 
chamber, which latter is consequently deepened, owing 
to the pressing backward of the iris and lens by the 
superabundant fluid. The pus-corpuscles and' small 
masses of coagulable lymph gravitate downward, and 
become deposited on the posterior surface of the cor- 
nea ; so that we need not be at all surprised at the 

general absence of these " precipitates " on the upper 
4 



74 SYMPATHETIC DISEASES OF THE EYE. 

portion of the cornea. The presence of these puncti- 
form deposits is pathognomonic of iritis serosa. Al- 
though, strictly speaking, they are not always deposits 
precipitated from the aqueous humor, nevertheless, 
the difference in their origin does not alter their diag- 
nostic value. If we puncture the anterior chamber 
and catch in a watch-glass a portion of the contents, 
together with some of the precipitates upon the pos- 
terior surface of the cornea, we may experimentally 
convince ourselves that these opacities are, as a rule, 
actual deposits, consisting of particles of coagulated 
fibrin, enclosing pus-corpuscles in greater or less num- 
ber. On the other hand, it has been found, during his- 
tological investigations, that these punctiform spots on 
the posterior surface of the cornea may also be caused 
by inflammatory changes in the epithelial lining of the 
membrane of Descemet, and even in the posterior 
laminae of the proper corneal substance. It need not, 
therefore, surprise us that these " precipitates " should 
now and then be observed, not only on the lower por- 
tion of the posterior corneal surface, but also opposite 
the pupil, and sometimes even scattered over the upper 
half of the cornea. Nevertheless, true inflammation 
of the membrane of Descemet, or genuine keratitis 
postica, is always to be regarded as characteristic of 
the serous form of iritis, inasmuch as it is directly 
excited by the morbid and irritating contents of the 
anterior chamber. It is chiefly the accompanying 



PATHOLOGY. 75 

turbidity of the aqueous which causes the hazy ap- 
pearance of all objects seen with the affected eye. 

It is important to note, in this connection, that while 
sympathetic iritis serosa usually appears under the 
unobtrusive symptoms above described, those forms of 
this affection which are independent of a sympathetic 
origin, are wont to be more distinctly and prominently 
expressed. In the latter, we not unfrequently notice 
very marked pericorneal injection, extreme deepening 
of the anterior chamber, and, instead of the fine punc- 
tated exudation on the membrane of Descemet, coarse, 
grayish, or even yellow, nodules, as large as pin-heads 
or hemp-seeds. It should, moreover, be distinctly 
borne in mind that we are not directly to diagnosti- 
cate iritis serosa, on account of the presence of nod- 
ules of exudation, but to look about for other 
alterations in the eye. If, for example, w& have 
simultaneously, an inflammatory adhesion of the mar- 
gin of the pupil to the anterior capsule of the Jens, it 
would be wrong to call the case one of iritis serosa. 
The precise difference between a serous and a plastic 
iritis lies in this fact, that in the serous form there is 
not a sufficient degree of plastic inflammation to effect 
any such adhesion between the edge of the pupil and 
the capsule. On the other hand, however, it is by no 
means uncommon, in a case of violent iritis plastica, 
to observe flocculent masses of pus or lymph floating 
about in the aqueous humor, as well as considerable 



76 SYMPATHETIC DISEASES OF THE EYE. 

proliferation of the epithelial cells of the membrane 
of Descemet. 

It is further important for ns to insist upon an ac- 
curate discrimination between the plastic and the 
serous form of sympathetic iritis. Sympathetic iritis 
plastica closely simulates, at the outset, common plastic 
iritis, which, as a rule, leads to only partial adhesions 
of the pupillary edge to the anterior capsule, but not 
tc a marked agglutination of the posterior surface of 
the iris to the capsule of the lens. Sympathetic iritis 
plastica is, on the contrary, very prone to develop into 
that more severe grade of iritis in which the adhesion 
rapidly involves the whole circumference of the pupil- 
lary border, so as to shut off all communication be- 
tween the anterior and posterior chambers, producing 
the condition technically termed exclusion of the pupil. 
Under these circumstances, the central portion of the 
anterior capsule, opposite the pupil, may still remain 
perfectly clear, or, at the most, be covered with so scanty 
a morbid product as not essentially to obstruct the pas- 
sage of the rays of light. When, on the other hand, 
the pupil is filled with a thick pseudo-membrane, or 
even with a dense plug of exudation, so that the pu- 
pillary area is completely abolished, the condition is 
called occlusion of the pupil. As the exclusion of the 
pupil may exist without its occlusion, so, conversely, oc- 
clusion may not necessarily involve exclusion. For it 
is easy to comprehend that a false membrane may 



PATHOLOGY. 77 

wholly cover the pupil without necessitating a con- 
tinuous adhesion between the entire circumference of 
the pupil and the anterior capsule; so that, at one 
point or another, beneath the edge of the membrane, 
an opening, however small, may still remain, and so 
preserve the communication between the two chambers. 
Occlusion of the pupil, although obstructing the 
passage of the rays of light, may cause no real dam- 
age to the eye itself ; but exclusion of the pupil, while 
presenting no direct barrier to the vision, very fre- 
quently destroys the affected eye. We may conceive 
that the aqueous humor is secreted by the ciliary pro- 
cesses and iris, or perhaps only by the posterior 
surface of the latter. We know, besides, that the 
aqueous normally finds its way out of the anterior 
chamber, by filtration and diffusion into the veins 
immediately adjacent to its periphery. If, now, the 
communication between the anterior and posterior 
chambers is abolished by exclusion of the pupil, the 
fluid secreted into the posterior chamber, from the 
ciliary processes and the posterior surface of the iris, 
is deprived of its normal means of escape into the an- 
terior chamber, and then into the pericorneal veins, as 
well as into the sinuses of the ligamentum pectinatum 
iridis, so that an abnormal accumulation of aqueous 
takes place in the posterior chamber. It happens, 
therefore, as soon as the pressure of the fluid in 
the posterior chamber exceeds that in the anterior, 



78 SYMPATHETIC DISEASES OF THE EYE. 

that the inequality manifests itself by the bulging for- 
ward of the iris into the anterior chamber, except at 
those points where it is held back by the adhesions. 
The protrusion forward of the periphery of the iris, 
accompanied by a crater-like depression of its pupil- 
lary edge, is, therefore, a sign of exclusion of the pupil. 
So long as this phenomenon is absent we cannot diag- 
nosticate exclusion of the pupil ; for, even with the 
assistance of mydriatics, we are unable to declare 
positively that some minute hole does not exist, at one 
point or other, around the apparently completely ad- 
herent margin of the pupil. 

Now, this imprisonment of the aqueous humor be- 
hind the iris, with the jutting forward of the periph- 
ery of the latter membrane, almost invariably leads to 
a complex set of symptoms, which are comprised un- 
der the name of secondary glaucoma, in which, with 
more or less violent attacks of inflammation, the ten- 
sion of the eye increases and vision diminishes ; or the 
globe remains hard, while vision gradually decreases 
to utter blindness, without any intercurrent inflam- 
matory phenomena whatever. The extinction of vi- 
sion then depends upon a lesion of the optic nerve, 
producing its total atrophy. Glaucoma is that af- 
fection of the eye which, with evident hardness of the 
globe, and with or without inflammatory exacerbations, 
leads to blindness. When the glaucoma depends 
upon some affection previously present in the interior 



PATHOLOGY. 79 

of the affected eye — as in our case, for example, upon 
a bulging iris, produced by accumulation of fluid 
behind it — the disease is called secondary glaucoma. 
It follows, therefore, that secondary glaucoma may 
sometimes occur in a sympathetically diseased eye, 
and cannot always be regarded as a part of the sym- 
pathetic process. For when sympathetic iritis plastica is 
followed by continuous circular adhesions (exclusion 
of the pupil), and finally produces secondary glaucoma, 
the latter disease depends wholly upon the adhesions, 
and not at all upon the sympathetic origin of the latter. 
We should here incidentally remark that an inclina- 
tion prevails, whenever sympathetic ophthalmia is met 
with, to diagnosticate a cyolitis ; or when the signs of 
aplastic cyclitis are wanting, to find, at least, a serous 
cyclitis. But we are not of those who believe that 
the bulging forward of the periphery of the iris, in 
sympathetic ophthalmia, or in secondary glaucoma, 
furnishes sufficient ground for inferring the existence 
of any sort of cyclitis, inasmuch as an analogous con- 
dition of the iris may likewise be developed in com- 
mon inflammations of this membrane (which are quite 
independent of any sympathetic foundation), without 
properly exciting any suspicion of even serous cyclitis. 
The idea of assuming the presence of cyclitis, in the 
generality of cases of sympathetic ophthalmia, is just 
as unnecessary as the possibility of establishing the 
fact of its presence is questionable. 



80 SYMPATHETIC DISEASES OP THE EYE. 

The mildest form of sympathetic disease of the uveal 
tract is serous iritis; plastic iritis comes next in order 
of severity, chiefly on account of the annular posterior 
synechise, or exclusion of the pupil, to which it is so 
prone to give rise ; but incomparably the most serious 
manifestation of sympathetic uveal disease is the so- 
called iritis maligna, which is nothing else than a 
plastic irido-cyclitis. In iritis serosa, adhesions do not 
commonly take place between the iris and anterior 
capsule ; in plastic iritis adhesions occur, but they are 
as a rule, limited to the pupillary border of the iris ; 
whilst iritis maligna is characterized by extensive ag- 
glutination of the posterior surface of the iris to the 
anterior capsule of the lens. Inasmuch as, in iritis 
maligna, choroiditis is almost always superadded to 
the irido-cyclitis, and the integrity of the retina be- 
comes thereby threatened, sympathetic uveitis attains, 
in iritis maligna, its culminating degree of severity. 
For when the iris, ciliary body, and choroid are all 
involved in the inflammatory process, the eyeball is 
usually consigned to atrophy. 

It is not necessary for us at this point to sketch the 
symptoms of sympathetic iritis maligna, inasmuch as 
we have already (pages 26, 27, and 28) clearly de- 
scribed irido-cyclitis, as well as irido-cyclo-choroiditis, 
of the primarily affected eye, as they occur either spon- 
taneously or in connection with injuries ; and the sym- 
pathetic forms do not differ materially from the primary, 



PATHOLOGY. 81 

except in the more frequent opportunities we have for 
observing the former. In other words, the genuine 
form of the disease in question is much of tener seen in 
the eye affected by sympathy, than in the eye originally 
affected, in which latter the regular type of the disease 
is frequently obliterated by the immediate effects of 
the injury. 

What relationship and mutual dependences do we 
find among the different forms of sympathetic iritis ? 
What are their course and issue ? It is true that iritis 
maligna is more frequently met with than the serous 
or the plastic form of iritis ; nevertheless, the two last- 
named species of this malady are not so rare as is 
commonly supposed. Statistical inflammation touch- 
ing the comparative frequency of iritis serosa is not 
easily obtainable, because the great majority of indi- 
viduals who are affected with this variety of sympa- 
thetic disease certainly do not come under the notice 
of a medical attendant. It may be inquired how this 
is possible ? Is not serous iritis merely a forerunner 
of the more important kinds of inflammation of the 
iris ? Is it not the pioneer of iritis maligna ? We 
must promptly answer this question in the negative. 
Then, again, if the serous form of iritis were transmu- 
table into iritis maligna, we should probably find few 
opportunities to observe the former, for the reason 
that only the severer grades of iritis are likely to bring 
the sufferer under professional observation. The recog- 



82 SYMPATHETIC DISEASES OF THE EYE. 

nition, therefore, of sympathetic iritis serosa, as a dis- 
tinct affection, is not, in some respects, of great practical 
moment. It is, however, of importance for us to know 
that iritis serosa has no inherent tendency to lapse into 
the worst forms of iritic inflammation. Whenever a 
surgeon enucleates an injured eye, on account of sym- 
pathetic serous iritis, and, upon subsequently seeing 
amelioration of the symptoms, natters himself that his 
well-timed interference has happily prevented a sym- 
pathetic plastic irido-cyclitis, and blindness of both 
eyes, he has, in all probability, been the victim of a 
self -pleasing error. However, we do not here desire to 
anticipate a discussion of the indications for enuclea- 
tion, but only parenthetically to remark, that iritis 
serosa has nothing in common with iritis maligna, 
and, as a very general rule, runs a favorable course 
without extirpation of the eye first affected ; and fur- 
thermore, that when a case of sympathetic iritis serosa 
has degenerated into a worse form of iritis, after the 
enucleation of the first eye, the operation itself has, 
in all probability, been the cause of the new sympa- 
thetic process. 

The relationship which exists between iritis plastica 
and iritis maligna calls for some comment. It is very 
generally stated in connection with iritis maligna that 
adhesions between the greater portion of the posterior 
surface of the iris and the anterior capsule of the lens 
need not be present in order to establish the diagnosis, 



PATHOLOGY. 83 

but that, in the beginning, the adhesion may be limited 
to the pupillary border, while the periphery of the iris 
is, at the same time, bulged forward by the serum 
confined behind it. It is further averred that at a 
later stage of the affection the serous gives place 
to a plastic exudation, which then firmly and exten- 
sively glues together the iris and anterior capsule, and, 
by subsequent contraction, retracts the periphery of 
the iris. I will here place no significance upon the fact 
that I have never, in my personal experience, witnessed 
this transition from a protrusion to a retraction of the 
periphery of the iris; but I must openly say, that 
when I see total circular posterior adhesions, with 
bulging of the periphery of the iris, in a case of sym- 
pathetic ophthalmia, I do not think of diagnosticating 
iritis maligna, but only the common form of plastic 
iritis with exclusion of the pupil, especially as the ten- 
sion of the eyeball so affected is not diminished, but 
is either normal or augmented. Such an iritis, if 
secondary glaucoma should not supervene, might run 
a relatively favorable course. Nevertheless, I do not 
like to take the risk in such cases, but let the bulging 
of the iris be to me the signal for surgical interference. 
It is quite a matter of course that errors of diagnosis 
may sometimes occur in these cases, for the iris may 
not only be thrust forward by the aqueous humor im- 
prisoned in the posterior chamber, but likewise, by 
extensive plastic exudation in the same locality, as I 



84 SYMPATHETIC DISEASES OF THE EYE. 

was once convinced upon dissection of an eye. In the 
case here instanced, it was easy to see how the iris might 
have first been bulged forward, and then retracted at 
its periphery by the shrinking of the exudation. 

The course of iritis maligna varies according to the 
different structures involved in the inflammatory pro- 
cess. Sometimes it is almost wholly confined to the 
iris and ciliary body, so that the integrity of the vitre- 
ous and choroid (and consequently of the retina), is 
mostly spared. The eye, under the latter condition of 
things, retains perfectly or tolerably well its normal ten- 
sion (even when the inflammation has covered the pupil 
witli a pseudo-membrane), is frequently promptly sen- 
sitive to light and shade, and in cases where the pupil 
remains clear, or is obstructed by only a thin film, 
preserves a corresponding degree of vision. The 
majority of cases of iritis maligna, however, terminate 
in atrophy of the globe, on account of the consecutive 
inflammation of the choroid, so that perception of 
light is either totally extinguished, or reduced to an 
insignificant amount. 

In the form of sympathetic ophthalmia now under 
consideration (plastic irido-cyclitis), we sometimes no- 
tice a remarkable phenomenon, which is of great value 
in connection with the pathogeny of this, as well as of 
other sympathetic affections in which it occurs, and 
which will, therefore, be further discussed in another 
place, 



PATHOLOGY. 85 

It consists of the manifestation of pain, either spon- 
taneously or on pressure, at a spot on the sympathetic 
eye, corresponding symmetrically to a point on the 
injured eye, which is still spontaneously painful, or 
painful only to the touch. If, for illustration, the most 
painful place of the eye first affected is situated near 
the upper and outer edge of the cornea, perhaps at the 
spot where a scleral wound, with incarceration of a 
portion of the iris, has occurred, the chief or even ex- 
clusive seat of pain in the second eye will, likewise be 
located at a precisely corresponding point on the 
supero-temporal margin of the cornea. 

In the present relation another phenomenon which 
has been observed in several cases of sympathetic cy- 
clitis deserves mention. Schenkl discovered several 
silvery -white eyelashes on the temporal half of the 
upper left eyelid of a boy, nine years of age, at a 
time when this eye was sympathetically inflamed, in 
consequence of an injury received by the right eye. 
On the upper lid of the right eye all the eyelashes 
were perfectly white, with the exception of a minute 
portion of their extremities, which was very dark. 
Jacobi also noticed in an eye, sympathetically affected 
with irido-cyclitis, that the lashes of the nasal half of 
the upper lid were altered in color to snow-white, 
whilst on the outer half of the same lid the lashes were 
black and white in about equal proportions, the lower 
lid presenting merely a few white hairs. 



86 SYMPATHETIC DISEASES OF THE EYE. 

Have we now exhausted all the forms of sympathetic 
disease that may invade the uveal tract ? It would 
seem not. Let us first notice a case reported by Hor- 
ner (1873). In an eyeball which has long concealed 
a foreign body, symptoms of irido-cyclitis set in. In 
the opposite, heretofore healthy, but somewhat myopic 
eye, a rapidly progressing impairment of vision takes 
place. The ophthalmoscope reveals, in explanation of 
the latter defect, & peculiar form of patches in the cho- 
roid, chiefly in the neighborhood of the macula lutea. 
Very numerous, minute, yellowish white, imperfectly 
denned specks, are seen behind the retina. The dis- 
ease progresses painlessly and without signs of irrita- 
tion. The spots of exudation, in the choroid, enlarge 
and coalesce. After a year vision has become so much 
reduced that fingers cannot be counted at a greater 
distance than four feet with the central portion of the 
retina, and seven feet with excentric vision. The 
function of the retina suffers, in this case, in conse- 
quence of the extension of the choroidal exudation to 
the layer of cones at the yellow spot. There was no 
well-defined primary sympathetic affection of the 
retina. 

Vignaux (1877) discovered, with the ophthalmo- 
scope, a commencing atrophic choroiditis of sympa- 
thetic origin, which was the cause of a very pronounced 
disturbance of vision. 

The conjunction of choroiditis with retinitis (cho- 



PATHOLOGY. 87 

roido-retinitis) as a form of sympathetic ophthalmia, 
was described by v. Graefein 1866 ; although, accord- 
ing to the statement of Laqueur, a sympathetic neuro- 
retinitis had been previously noticed by ftheindorf 
(1864). After the extraction by v. Graefe of a dislo- 
cated chalky lens from the anterior chamber, cyclitis 
ensues in the same eye. Six weeks after the operation, 
the sight of the other eye, which has hitherto been per- 
fectly good, begins suddenly to be impaired, although 
no pain is noticed. The ophthalmoscope discloses a 
delicate and diffuse cloudiness of the retina all around 
the entrance of the optic nerve. Soon afterward, 
slight symptoms of iritis serosa are noticed, in the form 
of very delicate punctiform opacities in the membrane 
of Descemet. After vision has sunk to one-eighth of 
the normal amount, and the disease has continued at its 
acme for several weeks, a gradual but uninterrupted 
improvement takes place. The morbid appearances 
visible with the ophthalmoscope recede less rapidly 
than the functional disturbances. Disseminated patches 
of exudation are conspicuous on the choroid, for a con- 
siderable time, while the fine punctiform deposits on 
the posterior surface of the cornea are the slowest to 
disappear. The field of vision is complete in every 
direction, and vision is increased to four-fifths nor- 
mal. 

In the second of v. Graefe's cases, a patient, twenty 
years of age, blind in one eye since childhood, com- 



88 SYMPATHETIC DISEASES OF THE EYE. 

plains that the mined eye has been painful during the 
last few months. The globe of the best eye is moder- 
ately sensitive to the touch, and there is some impair- 
ment of vision. A slight haziness is diffusedly spread 
through the retina, circumscribed opacities are seen in 
the vitreous, and the choroid exhibits trivial alterations 
of structure. After enucleation of the blind eye, the 
sympathetic manifestations slowly disappear from the 
other. 

Schweigger (1875), however, alludes to the foregoing 
diagnoses of v. Graefe only to throw doubt upon them, 
and adds that it requires a number of analogous cases 
to supply satisfactory evidence of the correctness of 
such a diagnosis (sympathetic retinitis). For that 
reason we must here notice similar cases. 

Pooley (1871) reports two cases of sympathetic oph- 
thalmia, distinguished by the occurrence of nenro- 
retinitis. In both of them the injured eye was still 
abnormally sensitive ; whilst iritis, and molecular 
opacities in the vitreous, were conjoined with the 
retinal affection, in each case. Galezowski (1871) di- 
agnosticates sympathetic retinitis, characterized by 
whitish exudations and hagmorrhagic extravasations 
into the retina, followed by recovery, but with perma- 
nent obliteration of some of the implicated vessels. 
He supports his diagnosis by a similar case of Pol- 
beau's, which he observed with the latter. Gosselin 
(1872) speaks of a case of sympathetic inflammation 



PATHOLOGY. 89 

of the retina and choroid, marked by pigment spots, 
ecchymoses, and inflammatory exudations, together 
with a small posterior adhesion. The vision of 'the 
sympathizing eye became suddenly impaired, at a time 
when the stump, to which the opposite injured eyeball 
had become reduced, was the seat of an unusual ex- 
acerbation of pain. H. Miiller (1873) relates that 
Jacobson saw a sympathetic choroido-retinitis localized 
in the neighborhood of the entrance of the optic nerve, 
the other eyeball being at the time in a state of 
painful atrophy, ensuing upon cyclitis produced by a 
cataract operation. Hirschberg (1874) recognizes a 
sympathetic retinitis, characterized by great hyperse- 
mia of the retinal veins, together with slight diffuse 
cloudiness of the retinal structures, at a period when 
the opposite phthisical eye was still very painful to the 
touch over the ciliary region. Pfliiger (1875) meets 
with sympathetic symptoms in the form of inflamma- 
tion of the intra-ocular extremity of the optic nerve 
and the circumjacent portion of the retina. We have 
already mentioned this case, in which it was found, 
upon dissection, that an inflammatory infiltration of 
the iris, unaccompanied with cyclitis, was the lesion 
affecting the primarily diseased eye. Among the 
ninety cases adduced by Eossander (1876), sympathetic 
choroido-retinitis figures three times, although one of 
these cases holds its position with doubtful propriety, 
according to the opinion of Eossander himself. In 



90 SYMPATHETIC DISEASES OE THE EYE. 

Leber's work (1877), " Ueber die Krankheiten der 
Netzhaut und des Sehnerven " (On the Diseases of the 
Ketina and Optic Nerve), only a single paragraph is 
devoted to sympathetic retinitis. " The affection," says 
Leber, " is usually conjoined with serous irido-cyclitis 
and haziness of the vitreous ; after the media clear up 
the ophthalmoscopic evidences of the affection are 
sometimes unmistakable." The sympathetic retinitis 
is usually characterized by a diffuse cloudiness of the 
structures of the retina, to which a redness of the disc 
of the optic nerve is usually superadded. But, accord- 
ing to Leber, the retinitis is not simply associated with 
irido-cyclitis, but is dependent upon the latter ; for he 
commences by saying that "sympathetic irido-cyclitis 
also leads, now and then, to the development of reti- 
nitis." Finally, Vignaux (1877) narrates several cases 
of sympathetic choroido-retinitis, as well as of retinitis, 
without iritis or irido-cyclitis. In some of the latter 
cases the ophthalmoscopic changes are described so 
meagrely as to throw doubt upon the positive pres- 
ence of either choroiditis or retinitis, and the sympa- 
thetic affection in these cases miglit as well, or better, 
be accepted as amblyopia without underlying struc- 
tural changes. Nevertheless, the existence of retinitis, 
as an expression of sympathetic disease of the eye, can 
no longer be regarded as an open question. This kind 
of retinitis is very generally characterized by diffuse 
cloudiness of the retina ; but whether the sympathetic 



PATHOLOGY. 91 

nature of such forms of retinitis as Galezowslri and 
Gosselin describe, is to be established rather by the 
presence of other and deeper changes in the retina, 
cannot to-day be decisively settled. 

We should here notice a certainly very important 
point in connection with sympathetic retinitis. Schna- 
bel (1876) has stated (and Leber has likewise expressed 
a similar opinion) that common iritis is frequently 
complicated with diffuse retinitis. If, therefore, reti- 
nitis does not really appear as an independent sympa- 
thetic affection, but is only superinduced upon sympa- 
thetic iritis, the sympathetic character of the affection 
fails as absolutely as does that of secondary glaucoma, 
when the latter malady supervenes upon a complete 
posterior synechia of the pupillary margin of the iris, 
resulting from sympathetic iritis. Notwithstanding 
the occurrence of this complication, however, there is 
no doubt that retinitis,. without iritis and cyclitis, may 
arise in a wholly independent manner, from sympathy 
with the offending eye. I go even farther, and say : 
the frequent presence of irido-cyclitis, interfering with 
the employment of the ophthalmoscope, prevents the 
clinical establishment of the fact that retinitis is a 
very common manifestation of sympathetic disease ; 
or, in other words, that many more oases of retinitis 
are sympathetic than those in which clear and unmis- 
takable evidence of the fact can he obtained. The 
last suggestion is of importance in connection with 



92 SYMPATHETIC DISEASES OF THE EYE. 

the pathogeny of the sympathetic diseases, and we 
shall have occasion to resume it farther on. 

We leave the sympathetic diseases of the retina with 
the remark that the case of typical pigment-degenera- 
tion of the retina {retinitis pigmentosa), described by 
Robertson (1871) as a sympathetic affection, was mani- 
festly connected (Leber) with a binocular disease, 
which existed previously to the injury to which the 
supposed sympathetic disease was attributed. 

We now pass into an uncommonly dark province, 
viz., that of the sympathetic affections of the optic 
nerve. Sympathetic retinitis may, as we will here at 
once state, be propagated to the second eye along the 
path of the optic nerve ; but is the same statement ap- 
plicable to the other diseases of the optic-nerve tract ? 
Dransart has added much to the description of this 
subject : but we shall only mention his assertion that 
simple atrophy of the optic nerve is to be ranked aa 
one of the sympathetic affections. But he certainly 
weakens his statement very much when he includes 
"atrophy of the choroid, posterior synechise, and 
cataracts " among the " frequent accompaniments " of 
sympathetic atrophy of the optic nerve. Mooren saw 
a case in which atrophy of the optic nerve of one eye, 
caused by a contusion, was followed by atrophy of the 
optic nerve of the opposite eye. This last case is clearly 
entitled to be called an example of sympathetic dis- 
ease, in so far as every affection is to be regarded as 



PATHOLOGY. 93 

sympathetic, the reproduction of which in the second 
eye is ascribable only to a pre-existent disease in the 
first eye. The question, however, of practical signifi- 
cance is : Whether we can have simple sympathetic 
atrophy of the optic nerve in the second eye, under the 
same circumstances in which other sympathetic affec- 
tions generally become developed ? I would not like 
to deny off-hand the possibility of the occurrence of 
such a phenomenon. Indeed, from my personal ob- 
servation of two somewhat enigmatical cases, I cannot 
wholly avoid the belief that we may occasionally dis- 
cover the ophthalmoscopical picture of simple atrophy 
of the optic nerve, which is directly of sympathetic 
origin. 

We have already alluded to the danger of implica- 
tion of the second eye which now and then attends the 
enucleation of the first eye, when performed for prophy- 
lactic purposes, and it is now our purpose to describe 
the sympathetic phenomena which are sometimes 
seen in the second eye after the surgical removal of its 
mate. Colsmann (1877) removed an eyeball which had 
atrophied in consequence of an injury, and was omi- 
nously painful. A few days after the operation, the 
acuteness of vision in the remaining eye sank to one- 
seventh of the normal amount. Three days later the 
ophthalmoscope revealed distinct cloudiness of the op- 
tic disc and of adjacent parts of the retina, the cloudi- 
ness being especially conspicuous in the vicinity of the 



94 SYMPATHETIC DISEASES OF THE EYE. 

yellow spot. The field of vision was at the same time 
concentrically contracted. Under appropriate treat- 
ment pursued for six months, vision became normal 
and the visual field complete in every direction. Cols- 
mann also reported a second case of the sort, from 
Mooren's clinic. A few months after the prophylac- 
tic removal of an injured eyeball, the patient com- 
plained of subjective flashes of light in the remaining 
eye, but vision was still normal. Six months later, 
the acuteness of vision was exceedingly diminished, 
the patient only being able to read print the size of 
No. 19 of Jaeger's test-types (one and one-half to two 
centimetres in height). Inflammation of the optic 
disc, with very extensive cloudiness of the retina, was 
discovered with the ophthalmoscope. The final result 
of this case is not known. Colsinann states that Hugo 
Miiller had, at an earlier date (1873), described a case 
in which, five days after the removal of a degenerated 
and enlarged eyeball, the patient, without previous 
symptoms of sympathetic disease, began to complain 
of the periodical envelopment of the whole field of 
vision with a shining white cloud, accompanied by 
subjective sensations of light. In the intervals of 
these attacks, no impairment of vision could be ascer- 
tained, but the retina was cloudy in the neighborhood 
of the optic papilla. Later, however, without change 
in the ophthalmoscopic appearances, the power of vis- 
ion began to deteriorate rapidly, but was restored after 



PATHOLOGY. 95 

a course of treatment consisting of local abstractions 
of blood and the administration of mercury. We must 
not forget to add that, several months afterward, the 
patient experienced an attack of cyclitis, with increase 
of intra-ocular pressure (sympathetic glaucoma ?), 
which was successfully treated by iridectomy. 

We are here led to seek an answer to an important 
question : Is there a sympathetic glaucoma ? The 
question is not whether a sympathetically diseased eye 
can lose its sight while laboring under the character- 
istic symptoms of glaucoma (the glaucomatous symp- 
toms being, in such a case, simply superadded to those 
of the sympathetic disease), but it is whether primary 
glaucoma can be developed in the second eye, solely 
from sympathy with the eye first diseased. In other 
words, can a disease, whose symptoms, briefly expressed, 
are persistently increased tension of the eye, pulsation 
of the central vessels of the retina, and an affection of 
the optic nerve usually characterized by excavation of 
its intra-ocular extremity, arise directly from a disease 
or injury of the other eye, and continue, with or with- 
out inflammatory phenomena which have their seat in 
different parts of the eyeball, until the sight of the 
affected organ is destroyed ? 

Still another limitation must be made. It some- 
times happens, after the operation of iridectomy has 
been performed for the relief of glaucoma of the one 
eye, that the other, hitherto perfectly healthy eye, is 



96 SYMPATHETIC DISEASES OF THE EYE. 

attacked with the most violent symptoms of acute glau- 
coma, so that the patient, upon whom the operation 
on the first eye was, perhaps, undertaken merely for 
the removal of pain, and with no hope of restoring its 
lost sight, becomes totally blind. The question whether, . 
under these conditions, the outbreak of glaucoma in 
the second eye is of sympathetic origin, and ensues 
upon the operative injury inflicted on the first eye, in 
the same mode in which sympathetic disease may pro- 
ceed from any other kind of traumatic injury of the 
organ, is here answered in the negative, its fuller dis- 
cussion being postponed until we publish our work on 
the theory of glaucoma. 

Let us reduce our statement and inquiry to the fol- 
lowing terms : An eye is destroyed by irido-cyclitis, 
and the opposite eye becomes, in consequence of the first 
lesion, affected with sympathetic serous iritis. Every 
serous iritis, of whatever origin, may possibly cause 
secondary glaucoma. I have never personally seen this 
effect produced by sympathetic serous iritis ; but, even 
admitting its occurrence, the fact is beside our ques- 
tion. Then, again, instead of serous iritis, the sympa- 
thy may manifest itself in the shape of plastic iritis, 
which may excite secondary glaucoma by the round- 
about way of exclusion of the pupil. We cannot deny 
that this complication really may occur in the sympa- 
thetic eye, but the admission does not answer our ques- 
tion, which is : Can primary glaucoma be sympatheti- 



PATHOLOGY. 97 

cally produced in the second eye by an irido-cyclitis, 
or an irido-cyclo-choroiditis of the first eye ? 

Sympathetic glaucoma appears to have been first 
described by v. Graefe (1857). After narrating a par- 
ticular case, he superadds the remark that he has " re- 
peatedly met with a similar condition of things, viz. : 
absolute amaurosis of one eye, due to the destructive 
effects of choroiditis ; and amblyopia of the other eye, 
without any signs of irritation whatever, although the 
affection was accompanied with progressive limitation 
of the field of vision, as well as excavation of the 
optic nerve, visible with the ophthalmoscope." V. 
Graefe thought it possible that " disturbance in the cir- 
culation and secretion of the choroid might cause in- 
creased intra-ocular pressure and consequent cupping 
of the optic nerve entrance ; " in other words, a true 
sympathetic glaucoma. Many other published accounts 
of sympathetic glaucoma are extant (Horner, Mooren, 
Coccius, Carter, H. Miiller, Pomeroy, Rossander, Vig- 
naux) ; and divers authors who have, perhaps, no per- 
sonal knowledge of sympathetic glaucoma, accept it 
on the ground of v. Graefe's early observations. Nev- 
ertheless, this form of sympathetic ophthalmia falls 
somewhat short of general recognition. Maats (1865) 
refuses to concede it, and Brecht (1874) expresses his 
opinion that in v. Graefe's cases the supposed affection 
was mistaken for sympathetic amblyopia with limita- 
tion of the field of vision, without alterations of struc-- 
5 



98 SYMPATHETIC DISEASES OF THE EYE. 

ture. But the most powerful antagonist of v. Graefe's 
observations is v. Graefe himself. For in 1866, in 
connection with his first description of sympathetic 
choroido-retinitis, he emphasizes only two forms of 
sympathetic inflammation, viz., iritis maligna and iritis 
serosa, and positively asserts that sympathetic irido- 
cyclitis " never, or only in the rarest exceptional cases, 
shows any tendency to produce an increase of the 
intraocular pressure, or an excavation of the optic 
nerve." 

It now seems doubtful whether typical simple glau- 
coma without inflammatory symptoms, can be uncon- 
ditionally admitted into the group of sympathetic 
affections, especially since v. Graefe himself abandoned 
this theory, which he at first constructed upon the basis 
of a few cases which seemed to support it. I would 
further suggest that there is a manifest inconsistency 
in acknowledging the existence of this kind of sym- 
pathetic glaucoma, so long as it continues to be regarded 
as a secondary glaucoma following serous cyclitis. 
For the presence of serous cyclitis would, under the 
latter restriction, only be revealed by the glaucomatous 
symptoms; and in case the glaucoma were viewed 
simply as a product of serous cyclitis, the very nature 
of a primary sympathetic glaucoma would be preju- 
diced. Primary glaucoma simplex would then be 
nothing else than a serous cyclitis ; but to designate 
as a primary sympathetic glaucoma, a secondary glau- 



PATHOLOGY. 99 

coma resulting from serous cyditis, would be quite 
inadmissible. 

The existence, as a sympathetic affection, of acute 
glaucoma, i.e., primary glaucoma with all its peculiar 
inflammatory phenomena (which we shall not stop to 
describe in this place), must be regarded as extremely 
problematical, and as not hitherto satisfactorily dem- 
onstrated. Even the case reported by Jany (1877), 
who saw the right eye affected by what he supposed 
to be sympathetic acute glaucoma, during an attack 
of scleritis and iritis of the left eye, is lacking in 
some of the indispensable characteristics of a sym- 
pathetic disease. But the case is quite different, 
where increase of tension is superadded to those in- 
flammatory symptoms which are diagnostic of irido- 
cyclitis. Even where increase of intraocular pressure 
is noticed in connection with ciliary injection, sensi- 
tiveness of the ciliary body to the touch, adhesions be- 
tween the iris and anterior capsule, and opacities of the 
vitreous, glaucoma is not necessarily present, and cer- 
tainly not a sympathetic glaucoma. Augmented in- 
traocular pressure may be present during every acute 
inflammation of the eye, of whatever kind or origin. 
But if the increased intraocular pressure, under the in- 
fluence of which vision is sooner or later destroyed, 
is not permanent, although -it may be variable, the 
disease is not glaucoma. The heightened intraocular 
pressure, which may be present at one stage in irido- 



100 SYMPATHETIC DISEASES OF THE BYE. 

cyclitis, subsides in the generality of cases ; but even 
if this were not the case — if the eyeball remained ab- 
normally hard until vision were destroyed — the case 
would evidently be one of secondary glaucoma, en- 
suing on irido-cyclitis. The inflammatory symptoms 
of irido-cyclitis differ so widely from those of glau- 
coma, that there can be no risk of mistaking a pri- 
mary glaucoma for an irido-cyclitis. It is the irido- 
cyclitis, and not the secondary glaucoma developed 
from it, which is the sympathetic affection. 

A very peculiar form of sympathetic glaucoma, 
called sympathetic hemorrhagic glaucoma, was de- 
scribed by H. Pagenstecher (1877). Hemorrhagic 
glaucoma is characterized by the extravasation of blood 
into the retina, accompanied by the most violent symp- 
toms of glaucoma, so that the disease has sometimes 
been called a secondary glaucoma. According to the 
description given of Pagenstecher's case, however, the 
glaucomatous phenomena were first noticed, and sub- 
sequently followed by the retinal effusions. The left 
eye, from which the sympathetic affection in the 
opposite eye was supposed to proceed, showed at the 
time when its partner was affected nothing more than 
an ulceration of the cornea, which had not yet caused 
perforation. Later, a perforation of the cornea en- 
sued, and led to phthisis of the globe. At the date 
of the enucleation of the left phthisical and blind 
eye, its tension was augmented ; it was only moder- 



PATHOLOGY. 101 

ately sensitive to heavy pressure (consequently less 
sensitive than a healthy eyeball), and the cornea, 
which was flattened, and mostly converted into cicatri- 
cial tissue, was extremely anesthetic. The same an- 
aesthetic condition was noticed in the conjunctiva. 
The operation was followed by a decided improve- 
ment in the condition of the right eye, which, however, 
again became worse several weeks after the enucleation, 
during the course of a lobular pneumonia. It again 
improved; but, in consequence of the passing of the 
patient from observation, the case was not followed to 
its conclusion. Can any positive causal connection 
between the diseases of the two eyes be here made 
out ? The improvement of the abnormal tension and 
impaired vision, which followed the enucleation is 
very striking, and favors this view. But did not the 
rest and restricted diet (to which the " plethoric sex- 
agenarian, who was not averse to the pleasures of the 
table," must certainly have been submitted, for a time 
at least, after the operation) have an influence in pro- 
ducing the (possibly only transitory) change for the 
better? Certainly, the condition of the primarily dis- 
eased eye, as well at the time of the first " sympa- 
thetic " glaucomatous attack of the right eye, as at the 
time of the enucleation, was not such as to establish 
beyond a doubt its agency in exciting the disease of 
the second eye. 

To fill the complete catalogue of sympathetic dis- 



102 SYMPATHETIC DISEASES OF THE EYE. 

eases, we will further mention that Schmidt (1874) 
discovered a few opacities pervading the vitreous, in 
the form of grayish-black filaments, which he ascribed 
to a sympathetic source. There was no trace of ac- 
companying iritis, nor of other inflammatory processes 
in the uveal tract. 

Finally, Briere (1875) reports a case of sympathetic 
cataract. The opinion expressed by Briere, however, 
that the cataract described by him should be grouped 
among the sympathetic affections, is arbitrary. A 
well-authenticated case of sympathetic cataract re- 
mains for future discovery.* 

The severest forms of sympathetic disease are in- 
flammations of the iris, the ciliary body, and the 
choroid, on the one hand, and those of the optic nerve 
and the retina on the other. The serious lesions of 
the latter structures are usually concealed by the in- 
flammatory processes that simultaneously occur in' the 
uveal tract. Among the sympathetic affections of the 
uveal tract, iritis serosa constitutes a remarkable ex- 
ception to their generally dangerous character. It 
sounds paradoxical, but it is nevertheless true, that the 
existence of sympathetic serous iritis need excite less 
anxiety than that of sympathetic irritation, for the 

*Kriickow (1880) has, however, described two cases, in which 
the sympathetic cataract revealed itself, in each instance, in the 
form of an opacity, confined exclusively to the anterior capsule of 
the lens.— Tks. 



M 



PATHOLOGY. 103 

latter affection frequently sets on foot the worst forms 
of sympathetic ophthalmia, proceeding to the destruc- 
tion of the eye ; while genuine simple iritis serosa 
possesses very little inherent tendency to destructive 
results. 

Sympathetic ophthalmia is especially prone to be 
caused by injuries of the eye, because those morbid 
processes which constitute it are much more fre- 
quently of traumatic than of spontaneous origin. 
Modern ophthalmology, instead of diminishing the 
sources of sympathetic disease, has increased them. 
The linear method of extracting cataracts is one of 
these sources ; although, happily, when we place in the 
balance the advantages and the evils of this operation, 
the former outweigh the latter. The operation of irido- 
desis is less fortunate, and raises doubts. The more 
recent operative procedure of drainage of the eye 
awakens still graver doubts concerning the propriety 
of its employment. Drainage of the eye consists of the 
insertion and retention of a gold wire through the tunics 
of the eyeball, with a view to causing a continuous es- 
cape of the fluid contents of the globe along the canal 
occupied by the wire. It was the hope of the advo- 
cates of this method of treatment that it would, on the 
one hand, prevent the re-accumulation of subretinal 
fluid, in cases of detachment of the retina, and on the 
other, keep within normal limits the intraocular pres- 
sure in glaucoma, and thereby become an effective 



104 SYMPATHETIC DISEASES OF THE EYE. 

therapeutical agent in both these affections. But the 
injury to the eyeball incident to this operation will 
seldom be tolerated, and notwithstanding the transi- 
tory relief obtained, an insidious inflammation of the 
uveal tract will be set up in the great majority of 
cases, with imminent danger of sympathetic disease. ' 
I have, in fact, learned without surprise, that where 
eyeballs have been drained by this process, it has often 
become necessary to enucleate them, on account of 
the sympathetic affections which they have induced. 



SECTION IV. 



PATHOGENY. 

We will first make a few general remarks on the 
pathogeny of the subject under discussion. The fact 
that a disease of any part of the body should be the 
cause of disease in a symmetrical member must in any 
event seem something extraordinary. Human pathol- 
ogy up to this day has revealed but few phenomena 
of this nature. N orris, however, in his paper on sympa- 
thetic affections of the eye, speaks of a few analogous 
occurrences in other regions ; for example, one case 
by Mitchell, Morehouse, and Keen, in which, after a 
gunshot wound on the outer side of the thigh, com- 
plete anaesthesia was noticed on the corresponding 
side of the other thigh ; and another by Annandale, in 
which, after a wound on one hand had healed with a 
painful cicatrix, a similar condition developed on 
the other. 

Let us confine ourselves, however, to the eye, and at 

once inquire in what manner inflammation extends 

from one eye to the other. It would be an error to 

answer such a question in a general way. Entering 
5* 



106 SYMPATHETIC DISEASES OF THE EYE. 

therefore into details, we soon discover that the expla- 
nation is surrounded with difficulties of various degree, 
depending upon the locality of the inflammation. If 
we assume for example that the ophthalmoscope re- 
veals an inflammation of the optic nerve and retina 
in the sympathetically affected eye, and that we are 
justified in assuming a similar inflammation in the in- 
jured eye (whose deeper structures we are usually un- 
able to examine on account of entensive alterations in 
its anterior portion), we shall have no need of pro- 
found theories or the dragging in of obscure symptoms 
from other provinces of pathology, in order to under- 
stand what is going on. 

In case pathological anatomy does not plainly in- 
form us of any other way, we can assume in such • a 
case, that the inflammatory process in the optic nerve 
of the offending eye propagates itself centripetally 
(toward the brain); the moment that the chiasma is 
reached, the optic nerve of the second eye is threatened. 
It is of no consequence whatever, in so far as concerns 
the explanation of the phenomenon, whether we are of 
those who claim a total, or of those who claim a par- 
tial crossing of the optic nerves at the chiasma ; or 
whether we defend the view that all the fibres from 
one optic tract cross over at the chiasma to the optic 
nerve of the opposite side, or that a. part of these fibres 
remaining on the same side, go to compose the optic 
nerve of the same side. For, in every case, the fibres 



PATHOGENY. 1 07 

of both nerves lie so close together at the chiasma, 
that it would be miraculous if the extension of an in- 
flammatory process (particularly of the connective- 
tissue elements) were to confine itself, at the chiasma, 
to the fibres of one optic nerve, and carefully avoid 
the fibres of the second nerve which are so closely in- 
terwoven with those of the former. So far as con- 
cerns our present considerations, it is all one and the 
same, whether the process, after reaching the chiasma, 
advances or does not advance still further into the cen- 
tre of the organ of vision, along the corresponding op- 
tic tract. But this much is certain : that, so soon as the 
fibres of the second optic nerve are attacked in the 
chiasma, the inflammatory process' may extend not 
only toward the optic tract, but also toward the eye, 
and finally reach the terminal expanse of the optic 
nerve in the retina. 

The appearance of typical irido-cyclitis in the eye 
originally affected, accompanied with the develop- 
ment of optic neuritis in the second eye, does not in- 
terfere with the explanation just given, for in such a 
case we take it for granted that neuritis (or neuro-re- 
tinitis) is simultaneously associated with the irido- 
cyclitis in the first eye. But how can we explain a 
sympathetic inflammation of the whole choroidal tract, 
and above all, sympathetic irido-cyclitis plastica, which 
many oculists consider the most important, if not the 
only significant symptom of the sympathetic affection ? 



108 SYMPATHETIC DISEASES OF THE EYE. 

We might imagine that under such circumstances, also, 
the inflammation was propagated per contiguum. 
Thus, irido-cyclitis may always be the primary affec- 
tion in the eye first affected, while retinitis may be 
superadded to the original disease. The inflammatory 
process would then be simply transmitted along the 
tract of the optic nerves into the retina of the second 
eye, in which it could finally extend from the retina 
to the choroid. It is so common to see the choroid in- 
vaded by inflammation from the retina, that were a 
corresponding view permissible in the case of sympa- 
thetic affection of the uveal tract, all obscurities would 
be removed from the latter disease, and sympathetic 
inflammations could be regarded as simply transmitted 
continuously and per contiguum from the irritating 
eye through the chiasma. 

Although the affection of the optic nerve, first in 
the one eye, and subsequently in the other, is still too 
little appreciated, it is nevertheless a fact that sympa- 
thetic irido-cyclitis does not originate by this agency. 
For, at the time when the premonitory symptoms of 
this latter affection appear, the retina is very rarely, if 
at all inflamed. Otherwise, why should not the most 
typical symptoms appear in the choroid proper, which 
lies throughout in immediate and extensive contact 
with the retina \ In point of fact, it is the most 
anterior segment of the uveal tract (the ciliary body 
and the iris) which first suffers ; that very portion 



PATHOGENY. 109 

which is covered by a merely theoretical part of the 
retina, the so-called pars ciliaris retinse. As it thus 
appears that inflammation cannot be transmitted to 
the choroid of the opposite eye by the intermediation 
of the optic nerve and retina, we must either seek 
another path of communication, or else assume some 
remote and mysterious action. 

There is, however, one possible path of direct com- 
munication between the two eyes. I refer to the vas- 
cular circle of Willis, lying in the region of the 
chiasma, at the base of the brain, corresponding to the 
sella turcica, and embracing the chiasma as well as 
the tuber cinereum and corpora mamillaria. Altera- 
tions in the choroidal vessels of one eye migbt be 
transmitted to the chief arterial trunk (tbe ophthalmic 
artery) ; from there into the internal carotid, and so 
to Willis's circle; thence along the anterior arch of 
this circle into the opposite ophthalmic artery, and so 
tp the choroidal region of the second eye. 

Cohnheim has already shown us what an important 
role is played in inflammatory processes, by alterations 
in the vascular walls ; indeed in his opinion, " molec- 
ular alteration of the vascular walls," is the indis- 
pensable condition for inflammation. The only pecu- 
liarity with which we should meet in considering 
such a theory (even if all necessary assumptions were 
fulfilled) would be that the process in the second eye 
is never exhibited throughout the entire choroidal 



110 SYMPATHETIC DISEASES OF THE EYE. 

tract, but chiefly, or even exclusively, in its most ante- 
rior segment. Moreover, in the present state of our 
knowledge, we know nothing definite of any such 
direct transmission of inflammation along the vessels. 
By this, however, I do not mean to assert that the 
question of the participation of the vessels has yet 
been finally settled. 

We have, therefore, nothing else to do than to keep 
to the nerves, under which term we of course mean 
simply the ciliary nerves. The short ciliary nerves 
contain motor, sensitive, and sympathetic fibres; and 
we shall assume that every short ciliary nerve is com- 
posed of fibres of each of these three varieties. The 
long ciliary nerves which arise directly from the naso- 
ciliaris have no motor fibres ; of their sympathetic 
fibres we know nothing. Nevertheless, Strieker's ex- 
periments, which prove that hypersemia is caused 
whenever we irritate the sensitive roots of the spi- 
nal cord {i.e., that an irritation of the sensitive roo^s 
excites the nerves which dilate the vascular walls), 
would seem to show that the long ciliary nerves are 
made up in part of vascular nerves, which conduct 
irritation from the nerve-centre. 

"We are not inclined to acknowledge that the real 
motor nerves of the internal muscles of the eye, viz. : 
the corresponding fibres of the third pair, which sup- 
ply the sphincter iridis and the ciliary muscle, as well 
as those fibres of the sympathetic which supply the 



PATHOGENY. 



Ill 



dilator pupillse, have anything to do with the transmis- 
sion of sympathetic inflammation. There remains, 
therefore, for consideration only the sensitive fibres of 
the trigeminus, and the vascular nerves of the sympa- 
thetic. The question then arises, if the ciliary nerves 
are the only ones which act as conductors, does the 
capacity for transmission belong to each sort of fibres, 
or only to one, and to which ? So far as concerns 
the motor nerves, I would say that we sometimes 
meet with simple paresis of accommodation, as the 
only symptom of sympathetic irritation (Pagenstecher, 
Mooren, Schiess-Gemuseus). This symptom, how- 
ever, does not compel us to accept any action on the 
part of the motor roots. On the contrary, it can be 
explained in a very simple manner. The muscles of 
accommodation in both eyes contract synergically. If 
the contraction of one ciliary muscle becomes ex- 
tremely painf nl on account of some morbid affection 
which has attacked it, contraction at once ceases, and 
with it also the contraction of its partner. But just so 
soon as the injured eye is enucleated, the ciliary mus- 
cle of the second eye at once resumes its function. 

If it is the sensitive nerves which conduct the in- 
flammation, we must assume that either some indefina- 
ble irritation, or an unknown molecular alteration, or 
a distinct inflammatory condition passes along the 
fibres into the brain, and reaches the central nerve- 
cells from which the fibres proceed ; that this morbid 



112 SYMPATHETIC DISEASES OF THE EYE. 

process then "springs over" (or is perhaps transmitted 
by fibres) to the corresponding nerve-cells of the other 
side, and so, in turn advancing from the brain, reaches 
the terminal filaments of the sensitive nerves in the 
second eye. If the sympathetic fibres act as conduc- 
tors, then the irritation must cross over to the other 
side, in the vaso-motor centre, i.e., in the medulla ob- 
longata, or, if we give any credence to Strieker's ex- 
periments, beneath the medulla oblongata. 

It is relatively easy to assume some such state of 
things, for we thus safely avoid the dangers of " re- 
flex" action. But, admitting that all this is proved, 
many difficulties still confront us, in our endeavor to 
explain the origin of inflammation in the sympatheti- 
cally affected eye. The development of inflammation 
presupposes the fact that the irritation or inflamma- 
tion of sensitive nerves can produce the most violent 
inflammation in the tissues to which they are distrib- 
uted ; or, relatively, that irritation of the sympathetic 
fibres which dilate the vessels, or paresis of the fibres 
which contract the vessels, not only causes an enlarge- 
ment of the vessels (hypersemia), but even true inflam- 
mation. 

General pathology now busies itself but little with 
the influence which the nerves may exert upon inflam- 
mation, or denies it entirely. It is well worth observ- 
ing that, from this point of view, so little attention, or 
even none at all, has been paid to sympathetic ophthal- 



PATHOGENY. 



113 



mia. Herpes zoster— a disease in which inflammation of 
the bk in extends along the filaments of sensitive nerve- 

fibrei? is the only well-known example of the possible 

connection between an affection of the nerves and in- 
flammation, especially since the so-called neuropara- 
lytic inflammations— pneumonia after division of the 
par vagum, and keratitis after paralysis of the trige- 
minus— have been banished into the province of trau- 
matic inflammation. And even as regards herpes 
zoster, Cohnheim thinks that we ought to wait for 
further and more careful anatomical or experimental 
investigations, before building conclusions of so great 
an amplitude upon a very few facts. On the other 
hand, no one has ever yet observed the development 
of a genuine inflammation as the outcome of that 
hyperemia which depends upon division of the sym- 
pathetic nerve. 

In considering sympathetic cyclitis, however, we 
must suppose some such direct influence of the cili- 
ary nerves in the production of inflammation. In a 
clinical point of view, we have cases which afford 
such a hypothesis. In 1866 v. Graefe said: "It may 
be of interest' to note the fact that in two cases of in- 
jury, in which I did not enucleate the wounded eye 
because it still retained some traces of vision, I was 
able, at the outbreak of the sympathetic affection, to 
prove that the second eye showed increased sensitive- 
ness at a point, symmetrically to which a similar condi- 



114 SYMPATHETIC DISEASES OF THE EYE. 

tion was present in the first eye during the whole 
period of observation." Bowman has also made one 
observation of the same nature. 

■ Such exact symmetry as this is supposed to be ex- 
tremely rare in ophthalmology, and even authors who 
have had at their command a large amonnt of mate- 
rial for the study of sympathetic ophthalmia, cite only 
the three cases of v. Graefe and Bowman. Despite 
this fact, I am, nevertheless, firmly convinced that 
this phenomenon is by no means rare. Still, it is 
always remarkably striking, no matter how often it 
may be observed. I have seen it in genuine iritis 
maligna, as well as in severe plastic iritis, in which the 
circumference of the iris had become bulged forward. 
It is also sometimes noticed in that sympathetic irrita- 
tive condition which is usually regarded as ciliary 
neuralgia (page 63). If we carefully touch the region 
of the ciliary body of the sympathetically affected eye 
in these cases, we succeed in finding at some spot a 
pressure-point which is chiefly or exclusively sensitive 
or painful to the touch. If we then test the eye first 
affected, we are almost always sure to find an exactly 
corresponding spot over the ciliary region, which is 
chiefly or exclusively sensitive or painful. Although 
the originally affected eye frequently possesses but one 
painful spot, while the rest of the ciliary body re- 
mains quite insensible to the touch, or even to gentle 
pressure, so that, under these circumstances, it is suf- 



PATHOGENY. 115 

ficiently easy to discover the pressure-point in the eye 
first affected, we think it best to suggest that, in testing 
the sensibility of the ciliary body, we should begin in 
the eye affected secondarily. For the eye originally 
affected is sometimes so extremely sensitive to pain, 
that the attempt to discover if there be any especi- 
ally painful spot in the ciliary region, without know- 
ing exactly where to seeh for it, is barbarous, to say 
nothing of the fact that it may be impossible of ac- 
complishment. .But the circumscribed pain from pres- 
sure, in an eye affected sympathetically, is not precisely 
the same sort of pain as that which is produced by 
pressure in an inflamed region of the body. It is much 
oftener discovered, on the contrary, as has already 
been suggested, even where we have nothing but a 
neuralgia of the corresponding ciliary nerves — a neu- 
ralgia which may disappear without passing into a 
state of inflammation. 

If we reflect upon these facts, we can hardly do any- 
thing else than assume that the inflammatory irritation 
passes from the ciliary nerves of the one side to the 
corresponding ciliary nerves of the other, so that, 
finally, inflammation can be excited in the tissues to 
which these nerves are distributed. At present, how- 
ever, in these cases, it is absolutely impossible for us 
to tell whether the inflammation is transmitted by the 
sensitive nerves, which are evidently affected, or by the 
sympathetic fibres. Herpes zoster seems to show an 



116 SYMPATHETIC DISEASES OF THE EYE. 

active participation on the part of the sensitive fibres ; 
but we must not forget that, as sympathetic fibres are 
undeniably present in the ciliary nerves, we cannot, 
without further proof, deny the presence of the same 
sort of fibres in the sensitive nerve-trunks generally, 
as was demonstrated by Strieker's experiments, pre- 
viously mentioned. 

Having thus given a hasty and general glance at 
the subject, let us now see how the theory of the 
pathogeny of sympathetic inflammation has been built 
up in the course of time, upon the foundation of 
hypotheses, supported by clinical and pathological 
observations. 

If Mackenzie was not the first oculist to recognize 
sympathetic ophthalmia, we may claim for him that 
he was the first author who published any papers 
that show deep insight into this terrible disease. 
As early as 1844: he had already developed various 
hypotheses concerning the pathogeny of this affection, 
which contain very nearly all that has been discov- 
ered in this province in the last forty years ; while his 
works show that he had studied this obscure branch 
of ophthalmology much more carefully than is nowa- 
days generally believed. For, in looking over his 
writings, we see at once that he had already consid- 
ered the three paths along which sympathetic inflam- 
mation may possibly be transmitted: Firstly, through 
the vessels, by means of their anastomoses within the 



PATHOGENY. 117 

skull ; secondly, along the ciliary nerves ; and thirdly, 
through the retina and optic nerves. Nor do we now 
know much more about the manner of transmission 
than he did, for he says.: "The vessels on the side of 
the injured eye, being in a state of congestion which 
may increase to inflammation, perhaps communicate a 
disposition to similar disease to the vessels on the 
opposite side, with which they anastomose inside the 
cranial cavity." "The ciliary nerves of the injured 
eye might be the paths along which the irritation is 
conveyed, through the mediation of the third and fifth 
pairs, to the brain, from which it is reflected along 
the corresponding nerves of the opposite side." And 
finally, speaking of the optic nerves, Mackenzie says : 
"It is extremely probable that the retina of the in- 
jured eye is in a state of inflammation which advances 
along the corresponding optic nerve- to^the chiasma. 
From there, the irritative condition to which the in- 
flammation was due crosses over to the retina of the 
opposite eye, along its corresponding optic nerve." 

Correct as this last view must appear, even in our 
days, Mackenzie undoubtedly erred in regarding the 
"union of the optic nerves" as the " chief medium" 
by which sympathetic inflammation is produced. For, 
although there is not the least doubt that sympathetic 
neuro-retinitis is often developed in the manner which 
Mackenzie pointed out, sympathetic inflammation of 
the uveal tract, as we have already seen, cannot be ex- 



118 SYMPATHETIC DISEASES OF THE EYE. 

plained by the extension of an inflammation of the re- 
tina to the region concerned. So far back as 1849, 
Tavignot, as I learn from Mooren, regarded sympa- 
thetic iritis in the same light as if a sympathetic cili- 
ary neuralgia were the primary affection, leading 
finally to hyperaemia and inflammation. V. Arlt 
also showed, at a later date, that conduction along the 
ciliary nerves was the more probable path : "We can- 
not decide, in the present state of our knowledge, 
whether, in such cases, the optic nerve (the neurilemma 
as far as the chiasma) or the trigeminus and sympa- 
thetic ciliary nerves are the intermediate agents, al- 
though a majority of facts speak in favor of the latter." 
Heinrich Miiller (1858) was the first to awaken the 
attention of the ophthalmological world to the role 
that is played by the ciliary nerves. It is interesting 
also to note the fact that, from this time onward, the 
pathological views of sympathetic inflammation under- 
went very radical changes, although Miiller's views 
differ so slightly from those held by Mackenzie. 
Miiller, as well as Mackenzie, acknowledges that both 
the ciliary and optic nerves participate in transmitting 
the sympathetic irritation, but the former expresses 
himself in such a way that it seems as if he denied 
any such action on the part of the optic nerve. "Al- 
though I will grant that the ciliary nerves may often 
fan the fatal sympathy into flame, it is plain enough, at 
the same time, that I do not deny that sympathy 



PATHOGENY. 119 

(which assumes so many mysterious forms) cannot be 
transmitted by the optic nerve." 

Although H. Miiller followed in the general direc- 
tion which had been indicated by his predecessors, 
his opinions seemed the more trustworthy because 
they were for the first time based on anatomical con- 
ditions. Among others of this sort, Miiller found the 
ciliary nerves in a condition of partial atrophy, in an 
eye which had been enucleated on account of the 
premonitory symptoms of sympathetic ophthalmia. 
But, as the nerves had only lost their medulla, he 
thought that they might still have preserved " in a 
greater or less degree " their capacity for transmitting 
irritations toward the centre. " On the other hand," 
continues Miiller, " the optic nerve, in many cases, is 
in such a condition of excessive atrophy, from the 
retina as far as the main trunk, that it could hardly 
have the power of transmitting an irritation, or any 
other process, from the eye." Nevertheless, we must 
emphasize the fact that Miiller now spoils the effect 
of his last remark, by hastening to add that " we can 
hardly say, of certain fibres in the region of the 
lamina cribrosa, whether they are nervous or not." 
We must here carefully remark that Miiller had not 
discovered any anatomical condition by which the 
propagation along the ciliary nerves could in any 
way be demonstrated ; but that he simply based his 
conclusion upon the fact that the ciliary nerves are 



120 SYMPATHETIC DISEASES OF THE EYE. 

less liable than the optic nerves to degenerate into 
complete atrophy. 

As years passed by, the opinion that sympathetic 
inflammation was transmitted by the ciliary nerves 
grew more and more fixed, while, during the same 
period, the theory of the participation of the optic 
nerves in the sympathetic process fell into oblivion. 
Pagenstecher (1862) was probably the first observer in 
Germany who wholly opposed the participation of the 
optic nerves, and referred the transmission exclusively 
to the ciliary nerves, chiefly to their " nutritive " 
sympathetic fibres. For many years thereafter the 
ciliary nerves were regarded as the sole conductors of 
irritation from one eye to the other. Nevertheless, 
a few men (among them Mooren) could not but notice 
many facts that tended to show some transmission 
along the optic nerve. In these exceptional cases 
only a secondary r61e was attributed to the optic 
nerves. Thus, in 1869, Mooren says that every sym- 
pathetic disturbance depends upon an irritation of 
the ciliary nerves, but that the trigeminus may affect 
the optic nerves in the following manner: the irri- 
tation transmitted from the trigeminus to the optic 
nerve of the eye first affected, might be carried along 
this optic nerve to the second eye ; from the latter, 
in turn, it might extend from the optic nerve to the 
trigeminus, " so that the solution of transmitted irrita- 
tive processes takes place in the ciliary ganglion." 



PATHOGENY. 121 

But, beyond this obscure reflex action, it seemed to 
Mooren that a third factor was needed, in order to 
explain the origin of sympathetic affections : " one 
which fixes the relations of nutrition, secretion, and 
accommodation" — one which involves a co-operation 
of the sympathetic nerve, no matter whether the 
transmission is effected along the main branches, or 
directly along those sympathetic fibres which are said 
to accompany the optic nerve. 

The first observer, of recent date, to claim that the 
optic nerve plays the chief role in the transmission of 
sympathetic ophthalmia is Alt, who bases his opinion 
on anatomical discoveries, which show a large per- 
centage of alterations in the retina and optic nerve 
of the eye originally affected. We must not forget, 
however, that a large portion of these changes, such 
as the frequent occurrence of detachment of the 
retina, are nothing but the sequences of uveal dis- 
eases. We should mention, as' an additional point of 
interest, that Alt also observed three cases of sym- 
pathetic neuro-retinitis. Finally, the same observer 
subscribes to the extraordinary opinion, that the 
whole nervous apparatus shares promiscuously in the 
transmission of sympathetic irritation to the second 
eye, and that the various types of the disease in ques- 
tion show only a difference of degree: 

According to Mooren's theory, the nerves of special 
seme (that is to say, the optic nerves) would have 



122 SYMPATHETIC DISEASES OF THE EYE. 

to be additionally endowed with the capacity for con- 
ducting irritation. But if we assume that, at the time 
when the sympathetic symptoms appeared, there was 
no nervous connection between the foreign body and 
the optic nerve, and that it would be impossible to 
prove any conduction through the optic nerve, we 
should have to rely upon a different sort of (reflex) ac- 
tion between the ciliary and optic nerves, in order to 
explain certain sympathetic disturbances which are not 
of an inflammatory character. In the case already 
cited (page 67) of sympathetic contraction of the 
field of vision without any changes recognizable with 
the ophthalmoscope, JBrecht expressed his opinion, on 
anatomical grounds, that the optic nerves could not act 
as conductors. Nor could he imagine any other path 
for the transmission of sympathy than through the 
ciliary nerves. Brecht also thought it quite probable 
that the foreign body might have excited inflammation 
in some of the ciliary nerves, which have the property 
of transmitting irritation toward the brain ; that this 
inflammation extended step by step, and finally in- 
duced a hyperremic condition in the medulla ob- 
longata, with myelitis or some slight inflammatory 
process in the region of the vaso-motor centres. Sub- 
sequently, this inflammatory process caused paresis of 
the vascular walls', and hyperasmia of the retina in the 
second eye, which was the one at fault so far as con- 
cerned the disturbance of its function. Brecht based 



PATHOGENY. 123 

his argument on three experimental trials : first, 
those of Lewison on frogs (1869), from which the 
experimenter concluded that violent irritation of 
sensitive nerves paralyzes the reflex activity as well 
as those voluntary movements which are dependent 
on the medulla spinalis; secondly, on Leyden's opin- 
ion (1865) that the so-called reflex paralysis (para- 
plegia, paralysis of the sphincters), which is often 
ohserved after chronic affections of the bladder and 
other tedious diseases, may depend upon an inflam- 
mation of the sensitive nerves of the organ affected, 
which duly ascends into the spinal cord," and gives 
rise to a myelitis ; and thirdly, on the experimental 
studies of Feinberg (1S71), who observed paralysis of 
the bladder and paraplegia in a rabbit, a few days 
after cauterizing the ischiatic nerve, while at the 
post-mortem examination he discovered that the re- 
flex action was due to a myelitis, the central stump of 
the cauterized ischiatic nerve being quite intact. 
This goes to show that a similar inflammation can 
gradually extend along the nerve. Moreover, it is to 
be regarded as an experimental fact, which confirms 
Leyden's discovery in man, that whenever he had diag- 
nosticated, during life, a neuritis ascending into the 
spinal cord, he always found, after death, a cor- 
responding myelitis at the place where the nerves 
entered, but no tokens whatever of an ascending 
neuritis. 



124 SYMPATHETIC DISEASES OF THE EYE. 

"We may here mention still another possible hy- 
pothesis. The well-known experiment of Golz, in 
which a frog's heart ceases to beat when one strikes 
a few rapid blows over the region of the belly, may 
be interpreted to mean that the centripetal sympa- 
thetic nerves of the viscera conduct a reflex irritation 
through the medulla oblongata to the vagus, which is 
the retarding nerve of the heart. Now, in the same 
way, we might agree with Brecht in supposing that 
the irritation due to the foreign body is simply trans- 
mitted, by reflex action, along the sympathetic fibres 
of the ciliary nerves which lead to the brain {are 
there really any fibres of that sort?) through the 
medulla oblongata to the ciliary nerves of the second 
eye, which lead from the brain, and that the latter 
then interfere with the function of the retina itself, 
jnst like any other retarding nerves. Leber also 
(1877) is of the opinion that, inasmuch as the reflex 
paralysis of motor nerves has been abundantly dem- 
onstrated, as well by clinical observations as by expe- 
riments on animals, the occurrence of a reflex paralysis 
" of sensitive nerves, especially of the optic nerve or 
retina," cannot at present be denied without further 
argument. 

Those observers who defend reflex neuroses in the 
province of sympathetic affections, imagine, on the one 
hand, that the inflammatory irritation is undoubtedly 
conducted along the optic nerves, but that in the eye 



PATHOGENY. 125 

affected by sympathy the irritation crosses from the 
optic nerve to the ciliary nerves, by which the inflam- 
mation is first ushered in. Or, on the other hand, they 
assume that the sympathetic symptoms which reveal 
themselves on the part of the retina and optic nerve, are 
not produced in the second eye by direct conduction 
of the irritation from one optic nerve to the other, but 
by conduction along the ciliary nerves, and from the 
latter to' the optic nerve. According to these views, 
therefore, the whole series of symptoms, such as sensi- 
tiveness to light, rapid weariness of the eyes during 
work, rhythmical indistinctness of the field of vision, 
periodica] obscuration of vision, dread of light, sparks 
before the eyes, degenerating occasionally into exces- 
sive photophobia and photopsia, anaesthesia of the 
retina with concentric limitation of the field of vision, 
and finally typical retinitis (the latter separated from 
the other symptoms, at least by Leber, and regarded 
by him as the consequences of sympathetic irido- 
choroiditis) — all these symptoms, we say, are to be 
regarded simply as a series of reflex neuroses, the pri- 
mary affection having its seat in the ciliary nerves. 

The foregoing summary shows that we were right in 
designating our general views as relatively simple. 
But we will now go farther, and examine whether 
these relatively simple views will not satisfactorily ex- 
plain all the phenomena of sympathetic ophthalmia 
Without compelling us to enter upon the obscure pro- 



126 SYMPATHETIC DISEASES OF THE EYE. 

vince of reflex neuroses. "When Mackenzie thought 
that there was very little doubt that the retina of the 
injured eye was in a state of inflammation, it seems as 
if he hit the mark precisely. Without being forced to 
assume some mysterious influence on the part of the 
ciliary nerves upon the optic nerves, it has now been 
proved that the injury itself is capable of exciting va- 
rious inflammatory processes in the interior of the eye, 

* 

and that they may (oftentimes, perhaps, from some 
definite lesion of the parts involved) rapidly attack the 
optic nerve. In this point of view, we find a very in- 
teresting fact in an insignificant remark of Brailey's, 
in his " Pathological Report for 1876." A boy, four 
years old, falls with a knife in his hand, and pierces 
the lower eyelid, and then the cornea, as well as a 
portion of the sclerotica right and left from the cornea. 
Four days later the eye is enucleated. The retina 
and choroid are both in situ. The entrance of the 
optic nerve is swollen and completely surrounded by 
a whitish opacity, near which lies a small capillary 
hemorrhage. The microscopic examination leaves no 
doubt of the swelling of the optic nerve. E. Williams 
reported at the International Congress in New York, 
in 1876, two recent cases in his own practice, in which 
the wounded and enucleated eye had been attacked, in 
the most surprising manner, by a very pronounced 
neuro-retinitis. In the first case (in which enucleation 
was performed a few weeks after the injury), "Williams 



PATHOGENY. 127 

observed the most extensive swelling of the optic nerve 
that he ever had seen. Hirschberg also expresses as- 
tonishment over a similar case in the same year. In 
this case also, as in the one reported by Brailey, the 
eye was wounded by a knife-blade, although enuclea- 
tion was not performed until nine months after the in- 
jury. The optic papilla was very much swollen, and 
surrounded by a well-developed wall, evidently due to 
hyperplasia of the inner granular layer, and the radi- 
ating fibres of the retina. Inasmuch as the develop- 
ment of the neuro-retinitis in the injured eye has been 
demonstrated by Brailey, at an early date after an in- 
jury, as well as at a later date by both E. Williams and 
Hirschberg, and since the frequent participation of 
the optic nerve in the inflammatory process in the in- 
jured eye has generally been confirmed by Alt, we 
have on the whole to take it for granted that the retina 
and optic nerve in the eye first affected are either ir- 
ritated or inflamed by the wound itself, or by the mor- 
bid processes which follow the latter. It is, of course, 
hard to say wherein the " irritative condition " con- 
sists ; but it is a fact that the irritation can propagate 
itself to the second eye, or be produced in the second 
eye by inflammation in the first eye, as well as that 
the irritation can disappear after the removal of the 
original source of disturbance in the sympathetically 
affected eye. 
Just in the same way as the obscurations of the 



128 SYMPATHETIC DISEASES OF THE EYE. 

field of vision, as well as the diminution of central 
vision with concentric limitation of the field of vision, 
do not depend on diminished, hut on increased irri- 
tability of the retina — not on ancesthesia, but on hy- 
peresthesia of the retina, so the sensitiveness to light, 
rapid weariness of the eye at worJc,photop>hobia, flashes 
of light and sparks before the eyes, are manifestations 
of irritation propagated from the one optic nerve to 
the other. The eye which has become over-irritated by 
the sympathetic process refuses periodically, or perma- 
nently, to react in various portions of its field of vision, 
to the irritation of an amount of light which would 
be plenteously sufficient for an eye in a state of 
normal excitability. And, further in this connection, 
we must remember that v. Graefe long since rightly 
referred to hyperesthesia of the retina, that anaesthesia 
of the retina, with concentric limitation of the field of 
vision, which we observe in cases where there can be 
no question of sympathetic i/rritation. 

Some one may ask how it is possible for such a con- 
nection to exist between the eyes, by means of the op- 
tic nerves, in those cases in which the optic nerve of the 
eye first affected is in a state of total atrophy. A cord 
of connective tissue cannot transmit such a sensorial 
irritation ! Granted ; but even if this is so, we can- 
not, in my opinion, assume with absolute certainty, in 
all those cases in which similar functional disturb- 
ances are observed, without any material foundation 



PATHOGENY. 129 

in the second eye, that all the fibres of the optic nerve 
of the first eye are atrophic. How could we decide, 
even with the microscope, that some minute fibres 
which still had the capacity of acting like nerve-ele- 
ments, or axis-cylinders deprived of their medulla, 
might not still be present in the connective-tissue 
cord into which the optic nerve had become trans- 
formed ? When Brecht, therefore, thinks it impossi- 
ble that the optic nerves could have transmitted the 
sympathetic irritation in his case, and falls back on 
the ciliary nerves in order to support a theory of his 
own, he raises an unanswerable argument against him- 
self, by saying that the eye first affected was perfectly 
free from pain and irritation. In other words, his 
supposition of an irritative condition of the ciliary 
nerves falls to the ground. We do not, however, 
mean to assert that the functional disturbances of the 
retina, which have been previously mentioned, do not' 
depend upon alterations in the tissue concerned, even 
when the ophthalmoscopic image is negative. For we 
shall be compelled to assume some structural changes, 
even though they be coarse, when the irritation does 
not disappear after the source of irritation has been 
removed. Thus, in Alfred Graefe's terrible case 
(page 65). in which the tormenting photopsies did not 
yield after enucleation of the injured eye, I cannot 
doubt that they originated in, and were kept up by, 

the products of inflammation which had already 
6* 



130 SYMPATHETIC DISEASES OF THE ETE. 

taken firm hold of the optic nerves. The microsco- 
pist, in these cases, gives us an important clue in this 
direction, when he finds proliferated connective tissue 
in the intraocular end of the optic nerve belonging 
to the enucleated eye. Such a proliferation of inter- 
stitial connective tissue in the tract of the optic nerve 
would gradually compress the bundle of nerve-fibres 
more and more closely, and finally give rise to mere 
mechanical irritation. 

In previously speaking of evident inflammation of 
the optic nerve and retina of the second eye, we took 
occasion to emphasize the fact that there is no hinder- 
ance whatever to the transmission of such a process 
from one eye to the other. "We had only to prove 
that such a neuro-retinitis was really present in the 
eye first affected. Indeed, I should like to believe 
that, when the retina and optic nerve of the first eye 
have been found intact after enucleation in a few 
cases of assumed sympathetic neuro-retinitis, this very 
fact alone takes away every point of support in favor 
of the sympathetic origin of the affection in question. 

We now see why I so long ago emphasized the 
opinion that inflammatory affections of the nervous 
apparatus of the second eye really occur more fre- 
quently than observers have hitherto been inclined to 
admit, as well as that their presence is frequently hid- 
den by the simultaneous appearance of irido-cyclitis ; 
and, finally, that there is no necessity whatever for as- 



PATHOGENY. 131 

suming that they simply indicate the extension of the 
inflammatory process from the choroid of the same 
eye. Nor should we forget, in speaking generally of 
the transmission of inflammation along the optic 
nerves, that this might also happen in case the optic 
nerve of the eye first affected were completely trans- 
formed into a thread of connective tissue. For, even 
in such a structure as this, the inflammation might 
creep onward to the chiasma, and then appear in the 
trunk of the second optic nerve in the shape of a dan- • 
gerous peri-neuritis, embracing and crushing the fibres 
of the optic nerve by proliferation of connective 
tissue (a process which might finally reveal itself to 
the ophthalmoscope by partial or total atrophy of the 
optic papilla) ; or it might advance as far as the optic 
papilla, and there present itself to the eye of the ob- 
server under the form of optic neuritis. If we once 
hold fast to the fact that the optic nerve offers a very 
productive territory for the propagation of inflamma- 
tion, we can then eomprehend why optic neuritis may 
appear in the second eye after enucleation of the first, 
as in Colsmahn's three cases previously cited (page 
93). For, in these cases, the inflammation was either 
under way at the time when the operation was per- 
formed, and was only rapidly increased by the opera- 
tion, or else the operation led to the neuritis by crash- 
ing the nerve during its division. Such a crushed 
condition of the nerve was indeed directly acknowV 



132 SYMPATHETIC DISEASES OF THE EYE. 

edged by Mooren, in a case which he observed 1< 
before (1860) the cases cited by Colsmann. The 
tient began to complain of increasing dimness 
vision, photopsia, and slight pressure in the forehe 
a few weeks after the enucleation of the injured e 
Corrosive sublimate was exhibited internally, an< 
seton placed in the neck ; but several months pas 
before the subjective symptoms disappeared entir< 
The final history of the case showed that, two ye 
later, atrophic alterations in the optic nerve (as c 
firmed by the ophthalmoscopic examination) had 
duced the patient's vision so much that he felt i 
tnnate in being able to read Jaeger's test-types ] 
12, with difficulty. Who would not seek to expl 
such a case as this in the most simple way, by imas 
ing that the operation gave rise to a peri-neur 
which extended to the second optic nerve, and r. 
duced partial atrophy? 

We have, on the whole, no right at all to i 
whether the sympathetic affection is transmitted al< 
the optic nerves, or along the ciliary nerves / nor < 
we ask whether the transmission takes place along 
one path more frequently than along, the other, j 
the transmission may be effected in both ways. 1 
by this, however, we are not to understand that i 
and the same morbid process can be transmitted,, n 
along the one path, and now along the other. On 
contrary, irritative and inflammatory conditions i 



PATHOGENY. 133 

transmitted from the optic nerve and retina, along 
the optic nerves / whilst those inflammatory processes 
which are chiefly observed in that portion of the eye 
which is nourished by the ciliary nerves, and espe- 
cially in the uveal tract, are transmitted along the 
ciliary nerves. There is not the least doubt that the 
sympathetic inflammation may frequently be trans- 
mitted along both paths at once, or at short intervals, 
so that many symptoms in sympathetic affections of 
the uveal tract {amongst others, the functional dis- 
turbances) are not to be attributed to the inflam- 
mation of the uveal tract, but to a simultaneous in- 
flammation of the retina and optic nerve. 

This, of course, does not exclude the possibility of 
detachment of the retina, appearing in connection 
with the irido-choroiditis, involving the sympatheti- 
cally affected eye, just as it may be observed in every 
irido-choroiditis. In the same way, when we see sym- 
pathetic n euro-re tin itis in this same eye, the final de- 
tachment of the retina is not due to a sympathetic 
inflammation of the latter tissue, but to the process 
which is going on in the choroid. 

Moreover, as any irritation of the stump of the 
nerve, external to the eye, can induce sympathetic 
neuro-retinitis, it is easy to see (if we once acknowl- 
edge that the ciliary nerves, or, in a wider sense, the 
branches of the trigeminus, can transmit the irritation) 
not only how cyclitis of the one eye can produce 



134 SYMPATHETIC DISEASES OF THE EYE. 

affections of the whole choroidal tract in the otl 
but also how the same morbid processes, which ex< 
sympathetic affections in the ciliary body by irri 
ing the ciliary nerves, can similarly become an i 
tating cause in other regions of the eye, as well 
outside the eye, so soon as the filaments of the tri 
minus, which are distributed to the regions concern 
are affected in an analogous manner. From all 1 
we see that it is by no means extraordinary for irr 
tion (incarceration), or inflammation of the iris, 01 
the choroid itself, or for the irritation caused by 
artificial eye resting upon a stump, or finally, for 
mere introduction of an artificial eye into the 01 
after removal of the eye, to develop in the see< 
eye about the same train of symptoms that we obse 
after a genuine cyclitis in the first eye. In the lal 
point of view (the influence of an artificial ej 
Mooren was distinctly able to prove, in a case w 
great tenderness over the whole region of the stu 
of the optic nerve, how even a slight touch, upon 
inner wall of the orbit, produced excessive pain- 
fact which would go to demonstrate that the reg: 
to which the naso-ciliaris nerve is distributed ^ 
irritated by the sharp edges of the artificial e 
Moreover, a case of Snellen's, in which the sym 
thetic phenomena of irritation could at pleasure 
excited and then dissipated, depending upon whetl 
the artificial eye was inserted or again removed, she 



PATHOGENY. 135 

how much these phenomena in the second eye may 
depend upon the irritation of the empty orbit by the 
glass shell. 

Furthermore, we can see how enucleation itself, by 
crushing the ciliary nerves (and optic nerve) during 
their division, can become the starting-point of sym- 
pathetic inflammation, as well as how the curative 
reaction after a normal enucleation can excite the 
destructive disease in question by contracting the 
stump of the nerve in the cicatrix. In the same way 
it is easy to understand that, when the process in the 
first eye has once overstepped the rubicon, and is 
already advancing toward the chiasma along the ex- 
tra-ocular tracts, enucleation cannot prevent its en- 
trance into the interior of an eye which is still intact ; 
and finally, that even when the cyclitis (or neuro- 
retinitis) in the first eye is entirely cured, the same 
process may subsequently appear in the second eye, 
and there continue its devastating course. The enemy 
had indeed wholly evacuated his first camping-ground, 
but at the same time he was already advancing rap- 
idly upon the second eye. 

Now, just as I have seen cyclitis appear in the 
second eye after complete recovery from the same 
disease in the other, or seen the second eye exhibit 
the most violent type of cyclitis despite the fact that 
the other eyeball was perfectly free from spontaneous 
pain, as well as insensible to the touch, it might not 



L36 SYMPATHETIC DISEASES OF THE EYE. 

be at all impossible, after a normal recovery fr< 
snucleation, for some source of irritation to remain 
the orbital or intracranial fibres of the nerve 
volved. I think that, in every case in which we hi 
been obliged to ascribe the outbreak of sympathy 
symptoms to the enucleation itself, or to the introd 
tion of an artificial eye, we have, so far, observed, t! 
the region in the bottom of the orbit which was oc 
pied by the stump of the excised nerve, and its 
companying ciliary nerves, was sensitive to the tou 
as well as that the conjunctiva lining the cavity ' 
swollen, red, and painful. On the other hand, 
would seem unjustifiable for us not to recognize 
characteristic appearances of sympathetic irritati 
as such, simply because up to this time we had ne 
observed them in the absence of tenderness in 
orbit, as well as at the stump of the nerve. I alii 
now to the following case : 

March 25, 1878, 1 saw, for the first time, a fara 
aged forty-three, who had been wounded more tha 
year before, in the right eye, by the thrust of a co 
horn. A few days after the accident, violent pain ■ 
felt all over the corresponding side of the head. r . 
injured eye was enucleated at a later date, but the p 
did not cease. A year has passed since the enncleati 
but the patient has never been free from exacerl 
ing attacks of pain on the right side of his head. S 
he does not seek advice so much for the pain, as 



PATHOGENY. 137 

cause his left eye is totally unfit for work. He can 
use it so little, that it is only with the greatest difficulty 
that he can carry on his farm-work. He cannot read 
at all for more than a moment or two .at a time. The 
eye looks normal externally and the ophthalmoscope 
does not help me to discover any internal alterations. 
The patient can read diamond type (Jaeger No. 1), and 
his field of vision is normal. The only definite anom- 
aly which one can discover in the eye is that the 
power of accommodation is somewhat less than is 
usual at the patient's age. Despite, however, this 
nearly normal condition of the eye, the patient cannot 
work for any length of time, even with a convex glass 
to support his accommodation. We are therefore led 
involuntarily, in such a case as this, to assume the pres- 
ence of a sympathetic neurosis. But when we exam- 
ine the right orbit, We find that the cavity is lined with 
a conjunctiva which is neither red nor swollen, while 
neither in the bottom of the orbit, nor over the loca- 
tion of the stump of the optic nerve, can we discover 
any tenderness, nor even any special sensitiveness to 
pressure with a blunt probe. These various reasons 
had led several oculists to deny the possibility of any 
sympathetic affection in this case ; but I do not regard 
it as entirely impossible. The irritative cause, even if 
the peripheral ends of the nerves show no distinct 
anomaly, may lie anywhere in the nerve-tracts ; possi- 
bly even in the orbital portion of the optic nerve. In 



138 SYMPATHETIC DISEASES OF THE EYE. 

such a case, some remedy may yet be discovere 
scientific investigation. 

Another question now arises in considering 
pathogeny of sympathetic affections : If we ta 
for granted that the nerves transmit the irritatio 
we know anything more accurate regarding the m< 
of transmission ? We need not trouble ourselve 
cause, in the present state of w* Wowledge, " it i 
possible for ns to know anything " about the mole 
alterationg which may be present in the nerves di 
tjjg conduction of the irritation. But it is a 
striking fact that we really know nothing more 
cise as regards the manner in which inflammati* 
transmitted. But even in this point of view we 
distinguish between the ciliary nerves and the 
nerve. 

Alt searched for alterations in the ciliary nerv 
one hundred and ten cases in our province, but f 
only forty-three which offered any direct testis 
Thirty-four of these cases showed normal ci 
nerves. The remainder showed various lesions o: 
nerves in question, such as tearing, crushing (wii 
histological alterations), incarceration in a cicatrix, 
degeneration, atrophy, thickening of Schlemm's c 
and one case of calcareous degeneration in the 
canal. 

Goldzieher (1877) thought that he had unra\ 
the mystery, when he discovered in a given 



PATHOGENY. 139 

hich in my opinion is very doubtful, so far as re- 
rds its genuinely sympathetic origin) such extensive 
erations in the ciliary nerves of the enucleated eye 
no other observer had ever before seen. The whole 
ckness of the choroid was filled with fresh iuflana- 
itory swelling and proliferation of cells ; whilst the 
saths of the ciliary nerves were thickly infiltrated 
th round cells, and the inter-hbrillar tissues crowded 
th granules. Inflammatory nodules composed of 
nnd cells were also seen here and there compressing 
3 trunks of the optic nerves. If such a condition as 
!s were more generally observed, we should have at 
ist some anatomical proof that the ciliary nerves 
3 capable of propagating the inflammatory process 
thin the eye, as has already been proved in the case 
the optic nerves, even if we have, so far, been wholly 
able to determine with exactitude the paths along 
rich the inflammatory process is transmitted, outside 
3 eye. But Goldzieher's discovery is very excep- 
otial, and it cannot be denied that, in a vast major- 
of cases, the ciliary nerves of the eye which excites 
3 sympathy show no alterations whatever. Goldzie- 
r takes it for granted that the inflammatory altera- 
ns which he observed in the ciliary nerves are in- 
riably present in such cases, and assumes, in corre- 
Dndence with the experiments made on animals by 
esler, Feinberg, Klemm, and Niedieck, that the in- 
mmation in these nerves does not advance con tin u- 



140 SYMPATHETIC DISEASES OF THE EYE. 

ously, but by fits and starts, and that when it . 
reached the central organ it extends still farther ii 
similar manner. When the inflammation has fins 
crossed over to the nerve-tracts of the opposite side 
propagates itself in the same way, and so reac. 
in due season the network of nerves in the interior 
the second eye, along which, in turn, the dangerous 
flammation is conducted to the various membranes 
correspondence with the distribution of the ner 
concerned. So much for Goldzieher's opinion, 
which we may reply that the theory of a wander 
neuritis, as the anatomical cause of sympathetic 
flammation, lacks at present any satisfactory ba 
from the very fact that in almost every case the 
traocular ciliary nerves are decidedly intact, to 
nothing of the fact that no one has ever yet dem 
strated such a wandering neuritis, nor proved li 
such an inflammation in a nerve (even were it dem 
strated anatomically) could cause violent inflammat 
in a connective tissue. 

Dark and complicated, therefore, as must seem 
possible way in which inflammatory processes are trs 
mitted along the ciliary nerves, the matter is relativ 
simple in the case of the optic nerves, for in the 
ter we have only to picture the transmission of an 
flammation from nerve to nerve. Under such i 
cumstances as these, the inflammation of the o] 
nerve, in the injured eye, is anatomically proved- 



PATHOGENY. 141 

the eye affected sympathetically, it is directly proved 
with the ophthalmoscope ; so that here, with the union 
of the optic nerves at the chiasma, we may calmly as- 
sume that we have to do with a connected or discon- 
nected neuritis, passing from one nerve to the other 
through the chiasma. 

Another important question for us to decide is this : 
How long does it take for the irritation which ad- 
vances along the nerve-tracts to reach the second eye ? 
This is about the same as to ask when the sympathetic 
inflammation is liable to appear. We may at once 
reply that we cannot fix the latest period at which the 
disease in question may make its appearance. If an 
eye is totally destroyed by an inj ury, the possibility of 
its reacting upon the second eye continues, not only 
so long as the eye is painful, but in case a foreign 
body has remained harmlessly in the eye (even at any 
region whatsoever), it may at any indefinite future 
time be followed by a reaction due to the presence of 
the foreign body (page 24). Or further, in an atro- 
phic eye which, being utterly free from irritation, 
seems an extremely harmless neighbor, some un- 
known cause, or the development of a plate of bone 
in its interior, may give rise to renewed sensitiveness, 
and consequently develop a posthumous source of irri- 
tation (page 49). Finally, there can scarcely be any 
doubt that, in & painless and unirritable stump or eye- 
ball, the seeds of sympathetic irritation can rest un- 



142 SYMPATHETIC DISEASES OE THE EYE. 

germinated for an indefinite period (pages 48 and I 
In point of fact, literature gives us the history of a 
in which tens of years, even half a century, or Ion 
periods, have elapsed between the original injury 
exciting cause, and the development of sympath 
ophthalmia. 

It is much more important, however, for us to 
termine the earliest period at which the sympath 
affection may appear. In this point of view a ] 
portionately long interval seems, in our opinion, 
exist between the cause and the result. A priori, 
interval cannot be measured. We have no pre< 
starting- point from which to discover how long 
takes for the morbid condition in the ciliary and oj 
nerves to be transmitted to the opposite side. So tl 
While the earliest appearance of neuro-retinitis in 
injured eye has been precisely demonstrated, we 
not know, so far as regards the ciliary nerves, 1 
long a time must elapse before the ciliary nerveE 
the primarily affected eye are excited to the necess 
irritative condition. We might even believe t 
sympathetic neuro-retinitis must necessarily be de' 
oped in a much shorter time than sympathetic cycl: 
because the path along which the cyclitis advance 
much longer than in the case of the neuro-retinii 
nevertheless, we could by no meaus affirm that 
experience corresponds to our expectation. Macls 
zie stated that from one month to a month and a 1 



PATHOGENY. 143 

separated the original from the induced affection, and 
I must emphasize the fact that, in my own experience, 
I know of no case in which I ever saw sympathetic 
ophthalmia appear sooner than in four weeks after 
the injury. I grant, indeed, that this period of four 
weeks might be somewhat shortened, in occasional 
cases, but I will not grant that the necessary period 
can be reduced to a few days, as is alleged to have 
been observed by several authors. There are, however, 
some observations after enucleation, which would 
seem to argue in favor of the possibility of the rapid 
development of the sympathy, although they deserve 
to be carefully examined. We saw (page 94) how 
Colsmann and Hugo Miiller both observed one case 
each of neuro-retinitis in the uninjured eye a few 
days after enucleation of the other, and similar ob- 
servations are at hand in respect to uveal inflamma- 
tions (v. Graefe, Mooren, Schmidt, Pagenstecher, and 
Genth). But before we accuse enucleation of being 
the cause of the sympathy in these cases, we must 
prove that such an interval had not elapsed since the 
injury, as would have enabled the sympathetic inflam- 
mation to appear at that very same time, even if the 
enucleation had not been done, owing to the fact that 
the sympathetic irritation had long ago started on its 
path, and was just on the point of making its appear- 
ance in the other eye when the enucleation happened 
to be performed. When, in the case of the last two 



4:4 SYMPATHETIC DISEASES OF THE EYE. 

uthors, the first symptoms of sympathetic iritis 
ealed themselves in the previously healthy eye n 
[ays after the enucleation, we must remember t 
liirty-six days had already passed since the origi: 
tijury — a period in which the outbreak of sympathy 
phthalmia cannot surprise us, for it could not, at t 
ate period, have been restrained by an enucleat 
>erformed only nine days before. Schmidt's case 
omewhat similar: sympathetic inflammation appe 
n four days after the enucleation ; but here, a 
Learly four weeks have elapsed since the injo 
iVhen enucleation is performed in the case of e 
vhich have for a long time been phthisical and ps 
ul (Colsmann and H. Miiller), the sympathy wh 
ppears in a few days after enucleation can, with 
he less certainty, be referred to the operation. So 
re have pure cases — i.e., if one of two previou 
teal thy eyes is seriously injured, sympathetic irr 
ion will rarely appear before the fourth week ; i 
sdien fairly under way, can it be restrained by enuc' 
ion. 

The fact that a certain interval must elapse betwi 
he affection of the one eye and sympathy in the ot 
s of great importance in establishing our diagnosis 
, sympathetic disease. In order to make sucl 
liagnosis in any given case, we must weigh well 
hat has previously been given in detail in these pa^ 
mder the sections of Etiology and Pathology. I 



PATHOGENY. 145 

thermore, as we have already given a sufficient ac- 
count of the general course and results of the more 
important types of sympathetic ophthalmia, especially 
as regards irritation, and the manifold forms of 
affections of the uveal tract, we can at this place dis- 
pense with any special remarks on the prognosis of 
the disease in question. And so much the more read- 
ily, as several points in this respect will be mentioned 
under the title of Therapeutics, to which we will now 
give our attention. 



SECTION V. 



THEBAPEUTIOS. 

We finally turn our attention to the tkerapeutia 
sympathetic ophthalmia, and instantly we hear 
cry — I might almost say the battle-cry, "Enuc 
tion." Scarcely twenty years have passed away si 
v. Graefe said : " I should never think it necessari 
undertake the complete extirpation of an eye affec 
with traumatic irido-choroiditis, in order to ward 
a sympathetic affection from the other eye, an 
only mention this operation because, as I hear, it 
performed by some English oculists." Since tl 
thousands upon thousands of eyes have been sa 
ficed, and where is the oculist who feels wholly in 
cent of having operated under the philanthropi 
mantle of preventive enucleation, just for the sake 
gaining some especially desirable specimen for 
pathological collection ? 

Let us, however, enter calmly upon our discuss 
of this highly important subject. Before showing 



THEKAPEUTICS. 147 

beneficial results which enucleation may win for 
the patient, let us first inquire into the harm which it 
may cause. The most terrible result of enuclea- 
tion (an operation which consists in shelling out 
the eyeball from its surrounding capsule of Tenon, 
sparing as much as possible of the conjunctiva of the 
globe, as well as of the external muscles of the eye) 
is — death ! V. G-raefe witnessed two deaths, when he 
enucleated during the period of purulent panophthal- 
mitis, but none under any other circumstances. On 
the other hand, however, several fatal cases have been 
reported after enucleation of an eyeball which was 
not affected , with purulent panophthalmitis (Mann- 
hardt, Horner, Just, H. Pagenstecher, Vernenil, and 
Yignaux). The fatal cases reported by Horner, Pa- 
genstecher, and Verneuil were due to meningitis, as 
was demonstrated at the post-mortem examinations, 
although in the first two cases there was no evident 
proof that the process had extended from the orbit ; 
while in Verneuil's patient a phlegmonous inflamma- 
tion of the orbit was proved to be the connecting 
link. 1, also, once saw a fatal result after enucleation, 
in the case of an old woman whose right eye, after 
having undergone an iridectomy, continued painful, 
and had to be enucleated on account of absolute 
glaucoma. Profuse hemorrhage followed the opera- 
tion, and death ensued in a few days. The orbit ex- 
hibited traces of suppuration, but there were no signs 



148 SYMPATHETIC DISEASES OF THE EYE. 

of meningitis. On the whole, there was no discov 
able cause of death. There have undoubtedly be 
many more cases of death after enucleation th 
have ever appeared in print. For all that, 
shall see how mere chance may play its role 
this accident, from a case of my own, which will i 
easily be erased from my memory. An old wore 
had suffered for years with violent pain in a bli 
glaucomatous eye, which, with loss of sleep and ap 
tite, had reduced her to a very feeble condition, 
last she made up her mind to have the emicleat 
performed, and was received into the hospital. I p< 
poned the operation for some reason or other, to 
following day. But the operation was never perform 
for on the morning of the day appointed, the pati 
was found dead in her bed. Had I operated on 
day before, who is there who could not have said t 
the operation killed the patient ? The autopsy in I 
case, as usually happens, revealed no cause for deat 
We are next to notice that the enucleation of e 
which are sacrificed in order to protect the second 
does not always progress without accidents, leav 

* As partially bearing on the question of chance, let us rec 
case of our own, in which an iridectomy was appointed for a 
tain day, in a case of glaucoma. On the morning of the daj 
pointed, the patient was found dead in her hed. Ought noi 
extremely few cases of reported death from iridectomy to be a 
buted to some other than the alleged cause ?• — Ths. 



THERAPEUTICS. 149 

aside the very distant possibility of death. We may 
have extensive purulent inflammation of the orbital 
tissues without being able to discover any cause for 
such a course of events in the case itself, or in the 
operation ; intense phlegmonous swelling, accompa- 
nied with violent pain, may be developed in the orbit 
and lids, compelling us to make an exit for the pus 
by extensive incisions into the orbital tissues and sm - - 
rounding parts. At the same time, the general condi- 
tion of the patient is weakened, and we can congratu- 
late ourselves when the process confines itself to the 
orbit, so that all fear of its spreading into the cranial 
cavity is removed. 

Again, enucleation always causes a local disfigure- 
ment, respecting the degree of which there may, 
however, be different opinions. Moreover, in so far 
as the eye removed had a certain size, and the opera- 
tion was performed on a child, enucleation has con- 
siderable influence upon the configuration of the orbit 
concerned, as well as of the corresponding side of the 
face. There may of course be some discussion, in 
so far as regards the local disfigurement, as to which 
is the more comely, an empty orbit with sunken eye- 
lids (which, however, every one will cover with a 
handkerchief or bandage), or a misshapen stump, 
which cannot easily or agreeably be kept constantly 
covered. To be sure, we shall hear in reply that the 
difference really consists in this: that an artificial eye, 



150 SYMPATHETIC DISEASES OF THE EYE. 

fitted upon the stump, satisfies the cosmetic dema: 
more perfectly than when it is inserted into a vac 
orbit. The artificial eye, a hollow glass-shell, with 
concavity applied in corresponding size and curvat 
to the convex stnmp, deceives every one by the c< 
plete mobility which is imparted to it by the nrasi 
still fixed to their normal attachments — a real eye 
true to nature as often to deceive even the special 
if he does not look very carefully. It may, indt 
happen that the specialist himself mistakes the - 
for the other, the artificial for the natural, and 
natural for the artificial eye. If the concave shell 
the artificial eye is inserted into an orbit which 
been deprived of its eye, the mobility of the forme 
not, as is generally supposed, completely abolisl 
although the motion which it really has is extreir. 
slight. The operation of enucleation consists in 
moving the eyeball from Tenon's capsule. Now, 
external muscles of the eye, in their course from t] 
origin to their insertion on the globe, cross ovei 
Tenon's capsule, and have to penetrate it in ordei 
reach the sclerotica. But, at the very places wl 
this penetration occurs, the tendons of the mus 
become firmly united to the capsule. The invesl 
membrane of the vacant orbit is chiefly composed 
the conjunctiva of the eyeball, which now co 
the capsule of Tenon ; the latter in turn grasps 
muscles firmly at the fissures through which t 



THERAPEUTICS. 151 

originally passed. Now, if the remaining eye moves, 
the corresponding muscles on the enucleated side also 
contract, so that some slight movements are still 
noticeable in the lining membrane of the empty orbit. 
These, then, are the motions which are partly trans- 
ferred to the artificial eye, which is held firmly against 
Tenon's capsule by the pressure of the eyelids. 

Although this tends to show that complete enuclea- 
tion renders it impossible for lis so well to satisfy the 
demands of good looks as in the case of a stump which 
still remains in situ, we must nevertheless remark 
that this circumstance is of but little importance in 
the particular series of cases with which we now have 
to deal. For, if we have the slightest dread of sym- 
pathetic irritation or inflammation in the well eye, 
we shall never dare to place an artificial eye upon a 
stump which is more or less painful ; and even if we 
should by any means succeed in entirely freeing the 
eye from pain and irritation, we could never be sure 
of being able to apply the artificial eye directly upon 
the stump without the possibility of exciting sympa- 
thetic symptoms. Again, so long as the dangerous 
eye has a cornea, as may often happen, an artificial 
eye cannot well be worn ; and besides, if the atrophic 
eyeball has not diminished considerably in size, the 
glass shell cannot be used. 

Now, this cry of " mutilation " which has been 
raised by the opponents of too frequent enucleation, 



152 SYMPATHETIC DISEASES OF THE EYE. 

or of enucleation in general, cannot be accepted w: 
out a few words of explanation, for the early insert 
of unbreakable artificial eves may greatly compensi 
in the case of a child, for the disadvantages of a 
cant orbit, accompanied with a deformity of the ft 
or, more correctly speaking, for the inequality of 
velopment in one orbit and half of the face, in c< 
parison with the other side. And, on the other ha 
we must not forget that a minute stump will permit 
very same aspect of things that we dread so much 
the case of an entirely empty orbit. Thus, I have 
peatedly seen so small a stump after blennorrhoea 
the eyes of infants, that I was sure enucleation '. 
been performed, and only after positive assurances 
the contrary, was I able to discover in the botton 
the orbit a stump about as large as a pea, the c 
vexity of which could not be seen, but only f 
beneath the enveloping conjunctiva. It is therefoi 
matter of no account whether a stump of such a s 
or even somewhat larger, lies at the bottom of 
orbit or not. 

Death, cellular inflammation of the orbit, an< 
staring cavity (as well as other disadvantages of € 
cleation, such as excess of tears, and inversion of the 1 
accompanied with irritation of the mucous membr 
by the eye-lashes), have no direct relation to enucleai 
for sympathetic ophthalmia, but only to enucleai 
generally. The most important and most interest 



THERAPEUTICS. 153 

question for us is whether enucleation in and by itself 
can do any harm ; that is to say, can it endanger the 
other healthy eye by producing sympathetic irritation ; 
or by increasing a slight form of sympathetic inflam- 
mation already present, to a more violent, or even the 
most violent form of all ? 

"We have previously alluded to preventive enuclea- 
tion in those cases in which the sympathetic affec- 
tion appeared so quickly after the operation, that we 
could not but admit the possibility that the inflam- 
mation was already under way when the operation 
was performed. In such cases we can only say that 
the enucleation, at the most, hastened the sympathy, 
but did not really produce it. But the affair is quite 
different in those cases in which weeks or months 
elapse after enucleation, before the sympathetic symp- 
toms appear. Thus, for example, enucleation was the 
starting-point of sympathetic neuro-retinitis in the two 
cases of Mooren's previouslyme ntioned (pages 94, 132) ; 
it also caused a sympathetic " hyperesthesia ciliaris " 
in a third case of Mooren's, in which the enucleation 
of an eye destroyed by a gunshot-wound had been 
long before performed. "The starting-point of the 
irritation in the present case must be sought for in 
the inflamed end of the optic nerve of the enucleated 
eye." 

It seems to me, however, that we have much more 

important facts in those which tend to show that enu- 
7* 



154 SYMPATHETIC DISEASES OF THE EYE. 

cleation may increase those insignificant types 
sympathetic affection which would never have grei 
endangered the eye, to the most violent forms 
sympathetic inflammation. Mooren (1869) enuclea 
an eye affected with cyclitis, because the premonit 
symptoms of iritis serosa — " there were merely a : 
dots on the posterior wall of the cornea" — had 
peared in the other eye. In the fifth week after 
enucleation, Mooren for reasons unknown to us, m 
an iridectomy on the remaining eye, which was still f 
from pain. All went well for a time, but tli 
weeks later — two months in all after the enucleatioi 
a new and intense inflammation appeared, develoj 
finally into a genuine plastic irido-cyclitis, and 
stroyed the eye. 

Hasket Derby (1874) enucleated the eye of a yoi 
man with vision of ^ normal, because three, mon 
after an injury the other showed simple iritis ser 
(fine precipitates on the posterior wall of the cor: 
and slight dimness of vision). The deposits disappea 
after the enucleation, and the eye, with normal vis; 
became again fit for work. But two months Is 
irido-cyclitis appeared. Derby, suspecting irritatioi 
the stump of the nerve in the region of the cicati 
excised a quarter of an inch of the nerve, with its £ 
rounding tissue. Improvement again followed, but 
not last long. After several months, repeated atta 
of iritis, combined with opacities in the vitreous, 1 



THERAPEUTICS. 155 

reduced vision to ^ normal. The final result must 
have been very sad. 

Alt (1877) described the condition of an eye (in the 
case of a boy, aged nine years, injured seven years 
before by a needle) which was enucleated by Knapp 
for sympathetic iritis serosa. The behavior of the 
case after enucleation is interesting. The iritis serosa 
disappeared rapidly, but a plastic irido-choroiditis soon 
developed; vision sank to T -J- ¥ , then increased to ^. 
The termination of the case was unknown. 

This transformation of simple iritis serosa into gen- 
uine irido-cyclitis after enucleation, is an extremely 
suspicious event. We have already drawn repeated 
attention (page 81) to the fact that iritis serosa, if not 
treated too heroically, does not seem to have any 
tendency to develop into the more severe forms of 
iritis, and I must confess that I cannot understand 
how Moor&n (and others after him) can cite this 
case of his, as just quoted, as an argument against 
the opinion of v. Graefe and Donders, that iritis 
serosa never develops into iritis maligna under ordi- 
nary circumstances. Leaving entirely aside the fact 
that, in Mooren's case, an operation (iridectomy) was 
performed in the eye affected with iritis serosa, the 
ominous interval of two months between the enuclear 
tion and the violent inflammation, gives us a sufli* 
ciently distinct indication, not that the iritis serosa 
spontaneously increased to iritis maligna, but that the 



156 SYMPATHETIC DISEASES OF THE EYE. 

latter was caused by the enucleation (and would, per- 
haps, have appeared in precisely the same manner, 
even if the second eye, up to that time, had never 
been operated upon). 

We see the same state of things in Derby's, Alt's, 
and in many other cases, in which enucleation in 
iritis serosa has been " fruitless " — that is to say, in 
which the second eye has been destroyed by plastic 
irido-cyclitis after enucleation of the first. 

Samelsohn's case offers us a very instructive con- 
trast to that of Derby, who, animated as he was with 
the best intentions, and guided by the opinions then 
prevalent, sacrificed an eye which still possessed vision, 
in order to save its partner, but lost both of the eyes ; 
while, if he had not operated at all, both eyes might 
possibly have been saved. In Samelsohn's case, which 
is very similar to those just referred to, both eyes were 
really saved ; not, however, by the skill of the sur- 
geon, but by the persistent refusal of the relatives of 
the patient to have the proposed operation performed. 
We need hardly say, at this point, that we do not in- 
tend, in the slightest degree, to reproach the surgeons 
in question, but simply to utter our condemnation of 
those axioms according to which enucleation must be 
performed under such and such circumstances. 

Here is Samelsohn's case in brief (compare Knapp's 
Archives of Ophthalmology and Otology, vol. v., 
p. 48): A boy of fourteen injures his left eye by a 



THERAPEUTICS. 



157 



blow from the rebound of an elastic cord. Six weeks 
later fine dotted opacities appear on the posterior wall 
of the cornea, and, subsequently, a few delicate adhe- 
sions are noticed at the border of the pnpil. The in- 
jured eye shortly before the last inflammatory attack 
could still read large letters (Jaeger, No. 23) with an 
excentric portion of the field of vision ; finally, only 
fingers can with difficulty be counted. When the last 
attack in the left eye begins to decrease in intensity, 
the first symptoms of pericorneal injection, together 
with the characteristic opacities on Descemet's mem- 
brane, are noticed in the right eye. Enucleation of 
the left eye is now proposed, but energetically refused 
by the friends of the patient. Six , weeks after the 
first appearance of the serous iritis, both eyes are not 
only free from inflammation, but from the least signs 
of irritation. The eye which had been affected by 
sympathy is perfectly normal. The injured eye has \ 
of normal vision, and shows only a slight contraction 
of the visual field. 

In my opinion, there cannot be the least doubt that 
iritis serosa may become transformed into iritis maligna 
by the operation of enucleating the other eye. But, even 
as regards a slight attack of iritis plastica, enuclea- 
tion cannot, under certain circumstances, be wholly ac- 
quitted of blame in furthering the transformation of 
the plastic into the malignant form of iritis. We must, 
however, make a separation between serous and plastic 



158 SYMPATHETIC DISEASES OF THE EYE. 

iritis. For, when we find a few adhesions in the second 
eye, before enucleation, while plastic irido-cyclitis de- 
velops itself afterward, we can say, with incomparably 
greater justification than if the case had been one of 
iritis serosa, that the posterior adhesions did indeed 
indicate the beginning of plastic irido-cyclitis, but 
that enucleation was simply unable to retard the pro- 
cess. We may be justified, moreover, in saying that the 
operation did not exercise any unfavorable influence. 
This is undeniably .correct in some cases, but not in 
all. For we frequently observe cases in which the 
iritic process increases to irido-cyclitis at such an in- 
terval after the enucleation, that there can be no 
doubt that the plastic iritis, if left to itself, would 
have passed off as a mild attack, whereas the enuclea- 
tion excited it to irido-cyclitis. We will here insert 
an appropriate case from Vignaux's rich experience : 
The eye causing the sympathy is blind, but entirely 
free from pain; the eye affected by sympathy is 
spontaneously painful, as well as painful to the touch 
over the ciliary region, and is affected with iritis ac- 
companied with slight adhesions at the lower edge of 
the pupil. Vision is £ normal. With the help of 
atropia the iritis disappears after the enucleation. A 
month later, vision is fully £ normal. Two months 
after the enucleation a terrible inflammation appears 
in the eye, and, after persisting for ten months, leaves 
the organ in an incurable state of total blindness. 



THERAPEUTICS. 159 

We have now uttered the paramount condemna- 
tory opinion against enucleation — i.e., that it may 
cause sympathetic inflammation in a previously healthy 
eye, as well as increase a mild inflammation to the 
most severe ; or, more correctly speaking, that it may 
frustrate the permanent cure of a slight inflammation, 
by causing one of the most severe type. Hence, it is 
really only of secondary importance for us to add that, 
after the outbreak of a genuine iritis maligna, enuclea- 
tion is not only of no benefit whatever, but that occa- 
sionally, when the sympathizing eye is extremely irri- 
tated, it really does harm ; it even accelerates the 
disastrous process. Those cases of genuine iritis 
maligna which have recovered after enucleation, prove 
nothing at all in favor of the curative agency of enu- 
cleation, for no one will dare to say that in these ex- 
traordinarily exceptional cases, the process would not 
have proceeded in a possibly favorable manner even 
without enucleation, to say nothing of the fact that 
many such cases of perfect recovery rest upon an 
error in diagnosis : the case was not a genuine plastic 
irido-choroiditis. 

• Now that we have thus learned the disadvantages 
attached to enucleation, and the dangers which it may 
possibly have in store for the patient, it will be much 
easier for us to decide upon the importance of enu- 
cleation in the therapeutics of sympathetic affections 
of the eye. 



160 SYMPATHETIC DISEASES OF THE EYE. 

The fatal results of enucleation do not trouble us 
much when we are deciding upon the operation, for 
the cases of subsequent death are altogether too rare. 
But, under certain circumstances, we still have some 
reserve in this respect. Almost all the German ocu- 
lists hesitate to enucleate during the height of fla- 
grant panophthalmitis, standing as they still do in 
dread of v. Graefe's two fatal cases (1863). This feel- 
ing goes so far, that a German operator even excused 
himself for having enucleated two panophthalrnitic 
eyes with the hest results, because he did not know at 
the time what v. Graefe had said on this point. Per- 
sonally, I stand in awe of v. Graefe's advice never to 
operate if the panophthalmitis is distinctly pronounced. 
1 have never enucleated an eye under such circum- 
stances, and I donbt if I shall ever make up my mind 
to do so. The terrible apparition in v. Graefe's cases 
impresses me so deeply, that at the very sight of any 
eye in a state of panophthalmitis, and the thought of 
enucleating it, the dread of a fatal result is conjured 
up before me. By this, I do not mean to say that it 
is entirely justifiable for us to abstain from the opera- 
tion, for the English oculists never pay any great at- 
tention to panophthalmitis when they desire to enucle- 
ate. Thus Critchett (of whom, as he himself laugh- 
ingly said, the story goes that he cannot go to bed 
without having enucleated at least one eye during the 
day) told me that he had never seen an accident under 



THEKAPEUTI08. 161 

the above circumstances. Vignanx also praises enucle- 
ation when thus performed ; still he lost one case out 
of nineteen, although we must consider the great age 
(eighty-one) of the patient in this fatal case. 

We do not mean in this place to treat of the general 
indications and contra-indications of enucleation, but 
only of enucleation as a therapeutical resource in 
sympathetic affections of the eye. Hence, we must 
justify ourselves for discussing enucleation in panoph- 
thalmitis. We have here brought up the subject, be- 
cause, in our opinion, panophthalmitis cannot be wholly 
acquitted of the fault of producing sympathetic symp- 
toms (although it is generally assumed to be innocent, 
on the ground that the 'acute purulent inflammation 
entirely destroys all the nerves in the interior of the eye). 
On the contrary, we are sure, that flagrant panophthal- 
mitis may sometimes induce sympathetic inflammation, 
so that a few weeks after the outbreak of the original 
disease, and even at the time when it has by no means 
entirely disappeared, the premonitory symptoms of 
sympathy may reveal themselves in the other eye. 
Moreover, we mention enucleation in this place be- 
cause when the panophthalmitis is excited by the pres- 
ence of a foreign body remaining in the eye, we can- 
not expect a permanent condition of rest in the 
atrophic eyeball, even after the process has ended, but 
on the contrary, permanent or occasional spontaneous 
pain, or pain upon pressure, as well as the over-threat- 



162 SYMPATHETIC DISEASES OF THE EYE. 

ening danger of sympathetic ophthalmia. So, if we 
venture to enucleate during the stage of panophthal- 
mitis, we may not only put an end to the sufferings of 
the patient, produced by the acute inflammation, but 
secure him from the danger of sympathetic disease in 
the other eye for the rest of his life. But if any one 
is restrained from the enucleation of a panophthal- 
mitic eye by the dread of a fatal result, the reasons 
which we have just suggested in favor of enucleation 
during this period, will not be urgent enough to over- 
come his fears. For the appearance of sympathetic 
ophthalmia during flagrant panophthalmitis, although 
observed by a few oculists, is so extremely rare as not 
to offer any general indications for the operation. In 
case, therefore, that the enucleation of the eye appears 
desirable as a precaution against sympathy in the fu- 
ture, we can wait until the panophthalmitis has grad- 
ually diminished under suitable treatment — in case we 
did not prefer to enucleate, or could not enucleate di- 
rectly after the injury and previously to the appear- 
ance of the panophthalmitis. 

Experience teaches us that when the irritation of the 
nerves has not yet extended to their extra-ocular 
branches, it is one of the rarest of exceptions for enu- 
cleation to lead to dangerous irritation in these latter 
filaments ; and that whenever this does occur, the im- 
perfect execution of the operation, or the crushing of 
the nerves during their division, is directly to blame in 



THERAPEUTICS. 163 

a considerable portion of the eases. We have, more- 
over, for the purpose of tabulation,. only a very small 
number of cases in which we can say that the operator 
unwittingly caused the stump of the optic nerve con- 
cerned to become constringed in the cicatrix. From 
all these remarks we see that there is but slight proba- 
bility of an intact second eye being endangered by 
enucleation of the first. And finally, so long as it 
has not been satisfactorily demonstrated, in any great 
number of cases, that enucleation increases a con- 
dition of simple irritation or mere disturbance of func- 
tion to distinct inflammation, then, from this point of 
view also, enucleation is, on the whole, by no means to 
be dreaded. 

To sum up our remarks, we have the following in- 
dications and contra-indications for enucleation. 

If the second eye is still perfectly normal, oculists 
generally have not, up to this time, agreed upon the 
point whether preventive enucleation is admissible. 
My rule in such cases is as follows : if the patient 
ia moderately intelligent, has good surroundings at 
his home, and can at any moment summon the 
counsel of a skilful oculist, preventive enucleation 
is not necessary. Some ophthalmologists claim that 
sympathetic inflammation can appear suddenly, and 
without any warning ; but such is not my belief. 
The intelligent patient, warned of the threatening 
danger and notified to appear at once upon the 



164 SYMPATHETIC DISEASES OF THE EYE. 

slightest disturbance on the part of the sound eye r 
will hardly come to us with a pronounced irido-cycli- 
tis, but at the first appearance of the slightest symp- 
tom of irritation. If, on the other hand, we have 
before us one of the lower classes, a patient defective 
in intelligence and in whom carelessness and mistrust 
of medical assistance are narrowly united ; one whose 
remaining eye is liable to be overburdened with severe 
labor, and who caimot, even with the best intentions, 
get the advice of an oculist; then we may employ 
all our eloquence in favor of a preventive enucleation. 
For, notwithstanding our most earnest warnings, as well 
as all our representations that the patient will be totally 
blind for life if he neglects to report at the proper 
moment — despite all sorts of promises on the part 
of the patient that he will seek advice when the slight- 
est irritation appears, we may never see such a patient 
again until vision shall have been irrevocably de- 
stroyed by a genuine attack of irido-cyclitis. Of what 
avail, then, to overwhelm the unfortunate patient with 
reproaches, to remind him of his promises, and even 
to fly into a passion, or to melt into pity, when he 
mildly says that he thought the eye would get well of 
itself, or that he sought help at the hands of some old 
woman ! 

The fact that the eye which is liable to cause sym- 
pathetic diseases at some future time still jjossesses a 
certain amount of vision, never contra-indicates the 



THERAPEUTICS. 165 

performance of preventive enucleation. Those who 
resort to preventive enucleation on principle, or who 
regard it as a necessary duty to advise the enucleation of 
an eye in any special case, should never let themselves 
be led astray by the circumstance that the injured or 
irritated organ still possesses some remnant of vision. 
The enucleation of an eye which still possesses the 
faculty of sight, or one in which some degree of vision 
might possibly be restored at a later date, may be an 
unjustifiable deed in the general province of ophthal- 
mology, but it can never serve as an argument in favor 
of abandoning preventive enucleation. For the removal 
of this eye assures the safety of the other, and no one 
should fear any subsequent objection to the operation. 
But frightful must be the silent accusation of one's 
conscience, when the patient in whom we regarded 
preventive enucleation as a necessity, but in whose 
case we were so weak as to be false to our convictions 
(simply because he still retained some vision in the in- 
jured eye), reappears before us with both eyes irre- 
trievably lost. Read, for example, this case of Vig- 
naux's : " A child about ten years old has received a 
blow on one of his eyes. Gayet is of the opinion that 
the eye should be enucleated, but abandons the opera- 
tion because the eye still possesses a certain amount of 
perception of light, and yj, is very hard to deprive such 
a young person of an eye which still offers some hopes 
for recovery of sight. Alter a short time the child re- 



166 SYMPATHETIC DISEASES OE THE EYE. 

turns with the fully developed symptoms of sympa- 
thetic inflammation. The injured eye is enucleated; 
but it is too late ; blindness becomes total." Gayet 
recalls this case to mind two years later, and says : " I 
shall regret this during the whole of my life." And I 
add, we hope that at the time when enucleation was. 
finally performed, vision was really wholly lost in the 
injured eye, for if it were not, Gayet added to his 
previous error of abandoning preventive enucleation 
(one, by the way, in which, on account of the prevalent 
difference of opinions, he might find easy absolution) 
a second more grievous and much less excusable error, 
as shall soon be dilated upon more fully. 

While discussing this point, I would like to add 
that I cannot see how Vignaux, while still depressed 
in mind by this case of Gayet's, could make such a 
remark as the following, one of the chief reasons 
against preventive enucleation : " Preventive enuclea- 
tion is generally contra-indicated in case the second 
eye exhibits perfect organic and functional integrity, 
and the originally injured eye still retains a certain 
amount of sight, or could obtain useful vision by 
operative interference at a later date." 

If the general symptoms of sympathetic irritation 
are already present, enucleation -must be performed 
at once. For, although cases have been known in 
which sympathetic irritation of the eye has lasted for 
years, and even decades, without really endangering 



THERAPEUTICS. 167 

vision, yet the physician cannot rely upon such a 
rare possibility in his own special case, in thinking 
over what remedy he shall employ. He must, on the 
contrary, regard the irritative symptoms as premoni- 
tory of the sympathetic inflammation, and, keeping in 
mind the danger that irido-cyclitis may be developed 
in a few weeks, even if no organic alterations are as 
yet present, he must decline all responsibility in the 
case, if enucleation is proposed to the patient, but re- 
fused. The oculist may act under such circumstances 
with energy and confidence ; for, notwithstanding the 
few exceptional cases in which the inflammatory pro- 
cess is already under way, even here enucleation gen- 
erally acts safely. 

When the other eye is in a state of irritation, an 
eye which still possesses vision must he unhesitatingly 
sacrificed : success is too certain, and too much is at 
stake, for the oculist to hesitate. If, in such a case, he 
meets the rare misfortune of seeing the irritation be- 
come developed into inflammation despite the enu- 
cleation, he can say with confidence : " All is lost, 
but not my peace of mind." The surgeon cannot act 
differently, and such a tragic accident as just sug- 
gested is so rare that the vast majority of operators 
pass through life without meeting with such a lament- 
able experience. 

If iritis serosa, and iritis serosa alone, is already 
present in the second eye, enucleation is, in my opinion, 



168 SYMPATHETIC DISEASES OF THE EYE. 

contra-indicated ; and the enucleation, under these cir- 
cumstances, of an eye which is not totally blind, is ab- 
solutely unjustifiable. I shall never again perform 
enucleation for sympathetic iritis serosa, for, as on the 
one hand this form of inflammation never shows any 
tendency to develop into irido-cyclitis, so, on the 
other, we have already offered proof of the deleterious 
influence of operative interference during the pres- 
ence of this disease. In such cases, in all probability, 
enucleation does more harm than good to the second 
eye. Nor could I decide to enucleate in a case 
of simple plastic iritis with a few adhesions, or 
even with adhesions entirely around the margin of 
the pupil. We see a case like Vignaux's (page 158) 
in the one reported by Hirschberg (1874), in which 
enucleation was performed ' within a few hours after 
the outbreak of a simple plastic iritis in the second 
eye. The iritis proceeded favorably, but, about three 
weeks after the enucleation, a relapse occurred and 
the eye was finally lost. Even if Hirschberg is cor- 
rect in assuming that the enucleation in this case was 
simply incapable of cutting short the irido-cyclitis 
which was already under way, the inexpediency of the 
operation would be evident. Under such circumstan- 
ces enucleation cannot be of any advantage ; it can 
only do harm. But we have already explained that 
plastic iritis is far from being synonymous with the 
primary stage of irido-cyclitis. For other reasons, 



THERAPEUTICS. 169 

however, a similar case of this sort will be mentioned 
farther on. 

Inasmuch as enucleation undertaken during a vio- 
lent inflammatory condition of the first eye is- of no 
benefit in the presence of sympathetic irido-cyclitis, 
and may even rapidly increase the pernicious inflam- 
mation, it follows that, when we still desire to enu- 
cleate, we should wait until the inflammatory process 
in the eye which has been first affected begins to show 
some relative pause. There is no general indication 
for enucleation in cases of sympathetic irido-cyclitis. 
If, notwithstanding this, the eye is enucleated in this 
stage, the main idea can only be that where all is ir- 
redeemably lost, there is nothing more to lose. Every 
one will admit that it is a crime in a case of pro- 
nounced sympathetic irido-cyclitis, to enucleate an eye 
which still possesses vision, or in which vision might 
at a later date be restored. It ought to be absolutely 
impossible for any oculist to have the opportunity of 
congratulating himself, at the refusal of the proposed 
enucleation of an eye which still possesses vision while 
the other eye is affected with sympathetic irido-cycli- 
tis ; because the omission of enucleation under such 
circumstances should never be'due to a lucky chance, 
but be dictated by the sagacity of the surgeon in 
charge of the case. Every one ought to know, and 
must know in such a case that enucleation cannot 
be of any avail. The oculist ought to know, even 



170 SYMPATHETIC DISEASES OF THE EYE. 

if there are several well-known cases in which irido- 
cyclitis has not led to total blindness after enuclea- 
tion, that this favorable result was not obtained by 
the enucleation, but despite it. Moreover, he should 
be aware, on the other hand, that numerous cases 
have been reported, in which the eye causing sympa- 
thy has saved the patient from everlasting darkness, 
for the very reason that this eye still retained some 
useful vision after the eye affected by sympathy had 
become totally destined. Y. Graefe said, after 
seeing two cases in which he refused to enucleate be- 
cause the first eye was not totally blind : " I was ex- 
tremely interested in these cases, by seeing perfect 
recovery from the sympathetic affection." 

My creed in the question of enucleation runs 
briefly thus : It may be performed as a preventive ; 
it must be performed in the stage, of irritation ; it 
cannot be performed in iritis serosa and iritis plas- 
tica ; it can be performed in irido-cyclitis plastica, 
provided the eye causing sympathy is totally blind, 
but not in a state of violent irritation. 

The most important point, so far as the general prac- 
titioner is concerned, is that he shall know the indica- 
tions and contraindications for enucleation. It is a 
matter of minor importance, whether, after having 
made a correct diagnosis, he can himself perform the 
operation, or feels obliged 'to refer the patient to a 
specialist for its performance. Still, I will in this 



THEKAPEUTICS. 171 

place describe the details of the operation, as well as 
its after-treatment. Augustus Pritchard, of Bristol, 
England, was the first to enucleate a human eye for 
sympathetic ophthalmia (1851). The term "enuclea- 
tion" owes currency in speech to v. Arlt, who pro- 
posed to use the term " enucleation of the eye " instead 
of " exenteration of the orbit ; " that is to say, " the re- 
moval of the globe from Tenon's capsule," in contra- 
distinction to the complete evacuation of the orbit, or 
the removal of the eyeball with all that lies behind it 
in the orbit. Y. Arlt reserves the expression " extir- 
pation " for the removal of some definite structure, such 
as a new-growth, from the orbit, with preservation of 
the eyeball. The shelling out of the eye from its 
envelope was first proposed by Bonnet (1841), and is 
performed in the' following manner by v. Arlt. 

Suppose that we intend to enucleate the left eye. 
The eyelids are kept apart by a stop-speculum, or, still 
better, by two lid-elevators in the hands of the assist- 
ant. In the latter case, by pushing the elevators along 
the lid, the assistant can separate the lids wherever 
the operator, for the time-being, requires the most 
room. The surgeon seizes the conjunctiva just over 
the insertion of the rectus externus muscle, with the 
forceps, divides it vertically with a pair of straight, 
blunt-pointed scissors, and then continues the incision 
in the conjunctiva half-way around the cornea and 
close to its upper edge, until he reaches the insertion 



172 SYMPATHETIC DISEASES OP THE EYE. 

of the internal rectus. He then returns to the origi- 
nal opening in the conjunctiva, and divides that mem- 
brane in a similar manner all around the lower margin 
of the cornea, but leaving a bridge of conjunctiva still 
standing at the inner side of the cornea, just over the 
insertion of the rectus interims. The next step con- 
sists in seizing the external rectus with the forceps, 
and dividing it completely ; not, however, between the 
forceps and the insertion of the muscle on the scle- 
rotica, but outside the forceps ; or, more plainly still, 
between the forceps and the outer angle of the eyelids. 
In this way we have the stump of a muscle still at- 
tached to the eyeball, so that by seizing this with the 
forceps we can rotate the eyeball in any desired direc- 
tion. One blade of the scissors is now directed up- 
ward beneath the tendon of the rectus superior, so that 
on closing the scissors the tendon of this muscle is 
completely divided from its attachment. After sever- 
ing the rectus superior, the rectus inferior is treated in 
a similar manner. If. we use a common stop-specu- 
lum, the assistant, having his hands free and possess- 
ing a sufficient degree of dexterity, can help the oper- 
ator a great deal by taking up the tendons of the vari- 
ous muscles with the common strabismus-hoot, and 
lifting them away from the sclerotica, so that it takes 
but an instant for the surgeon to pass the blade of the 
scissors between the sclerotica and the tendon, and to 
divide the latter completely. An operator of little 



THERAPEUTICS. 173 

skill, with an assistant of less skill, will of course 
help himself by taking up one muscle after another 
with the hook, before dividing them. 

The three recti muscles {the rectus internus yet 
stands), with the conjunctiva which still covers them, 
have now been divided, or, more correctly speaking, 
the tendons of the muscles, as well as the conjunctiva, 
have been loosened from the eyeball. Now comes 
the most important step, the festal moment of the 
operation — the division of the optic nerve. 

The optic nerve is inserted into the horizontal plane 
of the eye, but not precisely at its posterior pole ; not 
at the posterior end of the antero-posterior axis of the 
eye, but a little toward the nasal side. In order, 
therefore, to pass deeply into the orbit with the scis- 
sors, the eye must be first turned toward the nose by 
means of the stump of the external rectus. But if 
the eye rolls at all on its antero-posterior axis, the in- 
sertion of the optic nerve no longer lies in the trans- 
verse axis of the eye, but approaches either the upper 
or the lower wall of the orbit. In order to strike di- 
rectly across the optic nerve on introducing the scis- 
sors, we must be sure that the optic nerve remains in 
the transverse plane of the eye, which can only hap- 
pen when we turn the eye precisely inward by seizing 
the stump of the external rectus. Hence, we must be 
sure to notice, when turning the eye inward, whether 
it rotates at all on its antero-posterior axis. If this 



174 SYMPATHETIC DISEASES OF THE EYE. 

should take place, we are to move the eye back again 
to its original position, and repeat the manoeuvre until 
the correct position is reached. While the left hand is 
thus engaged, the right hand seizes a pair of strong, 
blunt-pointed scissors, curved on the flat, passes them 
(still closed) a short distance into the orbit along the 
horizontal plane of the eye, opens them, so far as is pos- 
sible without resistance, pushes them forward, and 
closes them rapidly. A certain resistance on closing 
the scissors, a distinct, grating sound, extremely agree- 
able to the ear of the operator (for nothing is more dis- 
agreeable, in the operation of enucleation, than to miss 
the optic nerve), and the possibility of immediately 
lifting the globe out from between the eyelids, show 
that the operation has succeeded. But, if we have 
been so unlucky as to miss the optic nerve, we should 
not attempt to reach it by repeatedly opening and 
closing the scissors while in the cavity of the orbit. 
For the optic nerve now lies outside the scissors ; it 
lies either above or below the latter. We should 
therefore remove the scissors entirely, once more care- 
fully rotate the eyeball inward, and then repeat the 
manoeuvre with the scissors. 

When the optic nerve has been divided, and the 
eyeball drawn out from between the eyelids with the 
forceps, we take it in our left hand, divide the inser- 
tions of both oblique muscles, then the rectus interims, 
next the bridge of conjunctiva which still stands at 



THERAPEUTICS. 175 

the inner edge of the cornea, and the operation is 
completed ; the eyeball, smooth and bare of all its at- 
tachments, with the optic nerve cut off close to the 
sclerotica, lies in our hand. 

If the right eye is to be enucleated, we begin the 
operation over the insertion of the rectus interims, 
then divide the rectus superior and rectus inferior, 
leaving the bridge of conjunctiva standing at the outer 
side of the cornea. We should also remember that, on 
account of the insertion of the optic nerve on the nasal 
side of the antero-posterior axis of the eye, the nerve 
is found at a much less depth when we operate on the 
right eye, than is the case with the left. 

The hemorrhage after the operation is generally 
slight. We may lay a couple of small plugs of char- 
pie, cooled by contact with ice, into the cavity, apply 
charpie over the closed lids, and over all v. Graefe'a 
compress - bandage (three or four turns of flannel), 
which is to be changed after twenty-four hours, and 
removed on the second day after the operation. In 
the course of recovery, the capsule of Tenon gradually 
becomes covered with conjunctiva, and in about a 
week we see at the bottom of the orbit nothing but a 
small suppurating and granulating surface, which soon 
cicatrizes completely. 

The first thing of which we should be absolutely 
sure in operating for sympathetic ophthalmia is to 
enucleate the right eye. This may seem idle advice, 



176 SYMPATHETIC DISEASES OF THE EXE. 

and even a joke; but, whoever like myself has once 
stood shudderingly by, while the eye which still pos- 
sessed vision was about to be enucleated instead of the 
blind eye, will not see a jest in these words of mine. 
The error is not inexplicable when we reflect that 
enucleation is frequently performed even when sym- 
pathetic cyclitis is already fully developed, so that 
there is really no obvious difference between the two 
eyes. Moreover, the operator is directing all his at- 
tention to the operation, and, being willingly led by 
the assistant, begins the operation on the eye to which 
the latter by mistake applies the speculum. The pa- 
tient makes no protest— for he is under the influence 
of anaesthetics. 

Anaesthetics have generally been resorted to in enu- 
cleation because the operation has been considered 
excruciatingly painful, especially during the division 
of the optic nerve, as well as of the ciliary nerves. I 
had always believed in this idea myself, and would 
scarcely have dared to enucleate without anaesthetics, 
had I not been compelled, in the case of a drunkard 
who really could not be chloroformed, to operate upon 
him in a conscious condition. I was not a little 
amazed when I fonnd that the section of the* various 
nerves was accompanied with no more acute expres- 
sions of pain on the part of the patient than during 
the first incisions in the conjunctiva. Since then I 
have repeatedly enucleated without anaesthetics, and 



THERAPEUTICS. 177 

have usually discovered, on questioning -the patients 
after the operation, that the first incision (in the con- 
junctiva) was more painful than the division of the 
nerves. Mooren once went so far as to say that, " in- 
asmuch as the operation is quickly performed, chloro- 
form is used only when the patient expressly desires 
it;" and again: "besides this, I can operate much 
more easily if the patient is not chloroformed." At 
the time when I read these sentences, I was so firm in 
the belief that the division of the nerves was extremely 
painful, that I could not credit what Mooren had said. 
But recent experience of my own has shown me how 
true it all is. 

Thus far for enucleation. The next question that 
comes up for our consideration is this : Inasmuch as 
the whole significance of the operation of enucleation 
depends upon the interruption which it causes in the 
conduction of irritation from the intra-ocular nerve- 
fibres to. the extra-ocular branches, can we not gain 
precisely the same result by simply dividing the optic 
nerve (neurotomy) ? 

The history, in brief, of neurotomy for warding off 

or curing sympathetic ophthalmia is as follows : In 

1857, v. Graefe said: "In order to decide whether 

the optic nerve takes an active part in the sympathetic 

processes of amaurosis, I have proposed in similar 

cases to substitute neurotomy for extirpation of the 

eye. Under precisely analogous circumstances we 
8* 



178 SYMPATHETIC DISEASES OF THE EYE. 

should, by adopting neurotomy, gain the advantage of 
preserving the eye." In 1865, Rheindorf reported a 
case of neurotomy performed for sympathetic neuro- 
retinitis, with scissors bent exceedingly on the flat, 
and rounded off at the points. Four days later the 
vision had increased by four numbers of Jaeger's test- 
type, and the recovery was permanent. The influence 
of the operation in this case could not be denied, for 
the excessive diminution of vision had persisted for 
months, during which period all treatment had been 
useless. The operated eye, at a later date, showed 
considerable injection of the anterior ciliary veins. 

In 1866, v. Graefe returns to the question once more. 
Nine years previously he had proposed to divide 
the optic nerve, not as Mooren thinks, because " the 
celebrated suggester of this procedure meant also to 
divide the ciliary nerves," but because in these cases 
it seemed to him that the optic nerve served as a con- 
ductor. At this time, however, it is the section of the 
ciliary nerves which v. Graefe proposes, although he 
doubts the propriety of dividing all of them out- 
side the eye, "on account of the necessarily exten- 
sive denudation, and especially on account of the si- 
multaneous division of the vessels." On the other 
hand, in case of circumscribed sensibility of the ciliary 
nerves, we might divide such as were implicated, out- 
side the eye, or perhaps better still, inside the eye, 
behind the flat portion of the ciliary body. Ed. 



THERAPEUTICS. 179 

Meyer first performed such an intra-ocular division in 
1866, and in 1867 and 1868 he reported this ease, as 
well as several others in which enucleation would have 
been indicated as a preventive, or on account of irri- 
tation already present. A narrow knife is passed 
through the sclerotica into the vitreous, and a section 
six to eight lines long (depending upon the extent of 
the painful region), and parallel to the margin of the 
cornea, is completed by simple counter-puncture, and 
division of the overlying bridge of tissues. In 1868, 
Secondi also reported a case of radical cure of sympa- 
thetic neurosis by intra-ocular ciliary neurotomy. All 
the tunics of the eye were completely divided over a 
space of a centimetre or two in extent, between the in- 
sertion of the rectus externus, and that of the rectus 
superior. Lawrence also reported a similar case in 
18C8. Ed. Meyer afterward continued to operate in 
this same manner, and in 1873 speaks of twenty-two 
cases of which he has heard. He thinks that intra- 
ocular neurotomy is really indicated as a preventive, 
as well as in cases of actual sympathetic neurosis. 

In considering the question of division of the ciliary 
nerves outside the eye, we are to distinguish between 
their division with preservation of the optic nerve, 
and the simultaneous division of both the ciliary 
and optic nerves. Snellen (1873) reports a success- 
ful division of some of the ciliary nerves behind 
the eye without doing any injury to the optic; nerve. 



180 SYMPATHETIC DISEASES OF THE EYE. 

The eye was totally blind, with excessive and cir- 
cumscribed tenderness to pressure at the upper and 
outer margin of the cornea. V. Wecker (Therapeu- 
tique Oculaire) recommends this operative method for 
cases in which the injured eye possesses better vision 
than the one sympathetically affected whose vision is 
totally lost. In his opinion we ought not to enucleate 
under such circumstances, but we may divide the 
ciliary nerves which surround the trunk of the optic 
nerve. Nevertheless, it is not plain from v. Wecker's 
account that he ever really performed the operation. 

The division of both ciliary and optic nerves behind 
the eyeball, as a general substitute for enucleation, 
was recommended by Boncheron in 1876, and subse- 
quently by Scholer and Schweigger. Scholer thinks 
that this operation is entirely safe in all cases of threat- 
ening sympathetic ophthalmia, while Schweigger is of 
the opinion that enucleation is only beneficial as a pre- 
ventive operation, and that, from this point of view, 
neurotomy is just as available as enucleation, which in 
his judgment has hitherto been opposed by the patient, 
on account of the dread " which the mutilation of one 
of man's noblest organs " must naturally arouse. 
Finally Hirsohberg, although he once published a 
paper opposing neurotomy, subsequently convinced 
himself, in two cases, that it succeeded in relieving 
ciliary pain, 

I would like in this place to make a few preliminary 



THERAPEUTICS. 181 

remarks on neurotomies in general. It seems to me 
that it is only a complete extra-ocular division of all 
the ciliary nerves, as well as of the optic nerve itself, 
that can be relied upon in cases of sympathetic affec- 
tion of the eye. It must be extremely doubtful 
whether intra-ocular neurotomy, i.e., the partial slitting 
open of the eye as above described, ever permanently 
relieves the eye so treated, or offers absolute security 
against sympathetic irritation in the other, even if it 
is performed several times in succession or in one dis- 
trict after another. Spencer Watson (1874) cites a 
case which was operated upon by Ed. Meyer's method, 
in which the primary result was very satisfactory, but 
it was not permanent, and enucleation had to be per- 
formed at a later date. On the other hand, there is 
no operation by which we can be sure of dividing all 
the ciliary nerves without doing any injury to the 
optic nerve. As for myself, I can see no indications 
for such an operation; for, in the _ case suggested by 
v. Wecker, we must not only postpone enucleation, but 
every operation on the injured eye, for it may still be 
saved ; whilst if this eye is blind, we 'must at the same 
time divide both ciliary and optic nerves for the pur- 
pose of. terminating the irritation which they inces- 
santly keep up. 

Among the opinions of various operators, on the 
division of the ciliary and optic nerves, we may quote 
that of Mooren (1869) : " I can hardly believe, in any 



182 SYMPATHETIC DISEASES OF THE EYE. 

case, that division of the ciliary nerves in the orbit can 
attain the purpose which its supporters claim for it; 
for, after fifty or sixty experimental operations for the 
division of various branches of the trigeminus, although 
I Lave usually seen a momentary and brilliant result, 
yet it has rarely been permanent. The desired effect 
disappeared as soon as the ends of the nerves reunited." 
V. Arlt also cites a case in the Zeitschrift der Wiener « 
Aerate, " in which he was sure that the ciliary nerves 
became reunited after once being divided." We have 
a perfect right to look at the subject ffom this point 
of view, for up to this time we have had no satisfac- 
tory assurance of the length of time during which the 
favorable result continues in cases of division of the 
nerves outside the eye. We can only assume that the 
ciliary nerves have been successfully divided when the 
cornea and ciliary body become totally insensible to the 
touch (or pressure) after the operation. Restoration 
of sensibility in either of these regions shows that the 
branches of these nerves bad subsequently reunited. 
I will at this place report a case recently under my 
own observation, in which reunion did take place, and 
at a relatively early period. 

A young man had been wounded in the left eye a 
short time before by a flying chip of wood. This eye 
now shows diminished tension ; the ciliary body is 
sensitive to pressure. There is slight ciliary injec- 
tion, the cornea is perfectly normal, the iris is dull in 



THEEAPEUTICS. 183 

color, its periphery is bulged forward in knob-like 
processes, and the margin of the pupil is attached to a 
thick membrane which covers the pupil. Perception 
of light is entirely destroyed. The patient now comes 
for advice, complaining that for some time his right 
eye has been momentarily sensitive to light, and that 
be cannot use it for any close work. The objective 
examination of this eye shows that it is normal in 
every respect. As the left eye is liable at any time to 
excite sympathetic irritation, while the complaints 
which the patient now makes may be regarded as the 
commencement of this condition, optico-ciliary neu- 
rotomy (as Scholer proposes to call the operation which 
we are now discussing) is performed — October 30, 
1880 — instead of enucleation. 

I open the conj unctiva over the tendon of the rectus 
externus, and extend the incision in an upward, and 
afterward in a downward curve, toward the insertions 
of the superior and inferior recti. 1 next take up the 
tendon of the rectus externus on the strabismus-hook, 
and carry the two ends of a catgut thread, No. 
(armed with a needle at each end), through muscle and 
conjunctiva. I then divide the tendon, and hand the 
threads with the muscle and conjunctiva to the assist- 
ant, to draw down into the external angle of the eye- 
lids. The next step consists in rotating the eyeball 
toward the nose, after which I penetrate, with scissors 
curved on the flat, into the cavity of the orbit, divide 



184 SYMPATHETIC DISEASES OF THE EYE. 

the optic nerve, and then alternately opening and 
closing the scissors, I denude the whole posterior sur- 
face of the globe as thoroughly as possible. The scis- 
sors are now laid aside. I then take a curved teno- 
tome, push it into the orbit, and denude the posterior 
portion of the globe still more thoroughly, turning the 
eye again and again as far as possible toward the nose. 
The subsequent hemorrhage is comparatively slight. 
The rectus extern us is now replaced and advanced by 
sutures ; the two needles are passed through the con- 
junctiva (which was previously left standing near the 
margin of the cornea), then removed, and the ends of 
the sutures tied. Finally, a pressure-bandage is ap- 
plied. 

November 2, 1878, three days after the operation, 
the cornea has lost all its sensitiveness, and the ciliary 
body is insensible to pressure. The ciliary region is 
now considerably injected, and the patient complains 
of violent pain. The conjunctiva also is extremely con- 
gested and very sensitive to the touch. The sensibility 
of the entire cornea soon returns. The ciliary body con- 
tinues insensible for a considerable length of time. On 
the last examination, however — December 10, 1878 — 
the upper and outer portions of the ciliary body are 
distinctly painful to pressure. • The eyeball is rather 
pale, deviates slightly outward, and is decidedly soft 
to the touch. The vague complaints about the unin- 
jured eye continue. Finally, enucleation is performed 



THERAPEUTICS. • 185 

by Prof. v. Jaeger. And what did we then discover? 
The stump of the optic nerve attached to the globe 
consisted of two parts. The optic nerve had been 
wholly severed by the neurotomy, but the two ends had 
reunited ; not indeed in perfect apposition, the two 
surfaces of the original incision being still in part 
plainly visible. 

The history of this case has also taught us the method 
by which the operation is performed. Schweigger 
divides the internal rectus in the middle of its inser- 
tion, instead of the external rectus, and reunites it af- 
ter the operation with sutures, as previously described. 
After dividing the optic nerve, he rotates the posterior 
pole of the eye forward, by means of a small, sharp 
hook inserted into the sclerotica near the optic nerve, so 
that the insertion of the nerve is brought forward into 
view. In this way we can carefully denude the whole 
sclerotica, so that the ciliary nerves shall be divided 
without the shadow of a doubt. But are we sure that 
some branches do not reunite ? If this should happen, 
it is not necessary for our purpose to take it for granted 
that the divided ends of the same nerve should always 
reunite with each other. The case which we have, just 
cited does not testify absolutely in favor of the com- 
plete reliability of optico-ciliary neurotomy. There- 
fore the operation must be tested further, perhaps 
improved a great deal, before we can employ it with 
confidence as a perfect substitute for enucleation. 



186 ' SYMPATHETIC DISEASES OF THE EYE. 

Meanwhile, we hope that no operator who puts full 
trust in it, and employs it as a preventive, in the be- 
lief that he thus insures the other eye from danger as 
thoroughly as he would do by enucleation, may ever 
be terribly undeceived by seeing a patient, in whom 
he has thus performed optico-ciliary neurotomy, reap- 
pear for advice at a later date, with all the symptoms 
of a genuine irido-cyclitis ! 

Among other operations proposed as substitutes for 
enucleation, we may next mention the production of 
purulent choroiditis by the early introduction of a 
thread into the threatening eye. It is said that, by 
passing a thread through all the tunics of the eye, 
and letting it remain until a slight serous swelling 
(chemosis) of the conjunctiva indicates that purulent 
choroiditis (panophthalmitis) has begun, the eye gradu- 
ally shrivels and becomes insensible. Moreover, it is 
6aid that the danger of sympathetic irritation is thus 
entirely removed, owing to the fact that the purulent 
inflammation has more or less completely destroyed 
the ciliary nerves. V. Graefe refers, at three differ- 
ent periods (1860, 1863, and 1866), to this manner 
of producing artificial atrophy, which had, however, 
long before been resorted to for an entirely different 
purpose, in the case of hypertrophied eyeballs. Fener 
also has lately revived the same proposition. Just 
here, however, we have nothing to do with the influ- 
ence of this procedure in diminishing the size of en- 



THERAPEUTICS. 187 

larged eyeballs, but only with its relations to enucle- 
ation. In spite of v. Graefe's recommendations, based, 
moreover, as far as we can see, on entirely theoretical 
grounds, we must emphasize the fact, which is easily 
evident from his own last words on this point, that he 
had»never made any practical use of this method in 
cases of sympathetic ophthalmia. These are his re- 
marks in 1866 : " It might, perhaps, he rational under 
certain circumstannes, especially after wounds or op- 
erations, when nothing more can be hoped for in the 
eye in question, to increase the diffuse purulent inflam- 
mation already present, by inserting a thread for two 
or three days. The patient suffers far less from the 
panophthalmitis (if soothed with cataplasms) than he 
would suffer from a subacute cyclitis, gains a less 
sensitive stump, which bears an artificial eye excel- 
lently, and finally is saved from the danger of trans- 
mission of irritation to the' other eye." 

But if this method really offers so great advan- 
tages, why had v. Graefe, up to that time, never re- 
sorted to it ? It seems to me that he had some fear 
that it might act as a double-edged sword. For, say- 
ing nothing of the fact that even panophthalmitis, 
and the " less sensitive " stump, do not offer complete 
security against sympathy, the thread, although it 
might not increase the inflammation to genuine pan- 
ophthalmitis, might cause cyclitis of a much more 
severe and dangerous type. Under such circumstances, 



188 SYMPATHETIC DISEASES OF THE EYE. 

this method might not only not remove the danger of 
sympathetic ophthalmia, but even favor the outbreak 
of this affection in the same way as, when a foreign 
body lies hidden in the eye, we cannot hope for a con- 
dition of permanent rest. 

Is there any need of my giving anything more "than 
a hint of the method proposed by Barton, which con- 
sisted in abscising the cornea, removing the lens, and 
subsequently applying poultices to the remnant of an 
eye in which a foreign body still lies encapsuled ? Or 
shall I mention the proposition of Verneuil (1874), who, 
after unfavorable experience in four cases of enuclea- 
tion, advises us to close the eyelids by uniting their 
edges (blepharoraphy), and illustrates the useful re- 
sult of this method by two pertinent cases % 

Barton tells us that, after abscising the whole ante- 
rior portion of the eyeball, and applying poultices for 
a few days, the foreign body, which has previously 
been lodged in the vitreous, is generally found lying 
somewhere in the conjunctival sac. This operation 
will, however, hardly take the place of enucleation, 
from the fact that it may possibly be followed by 
excessive secondary hemorrhage, as well as by violent 
and tedious panophthalmitis, so that the eyeball is 
gradually reduced to a minute stump. In Yerneuil's 
cases, the irritation of the eye which led to sympathy 
on the part of the other, depended, as Laquenr has 
already remarked, on a lack of suitable protection. 



THEEAPEDTIOS. 189 

Under similar exceptional circumstances, therefore, this 
operation may also be employed. 

Iridectomy is the last operation to be mentioned. 
Are we to perform it on the eye which causes sym- 
pathy? Under one circumstance only: when the iris 
(the eye being otherwise unharmed) has become incar- 
cerated in the peripheral wound in the cornea, after 
an injury or operation, as well as after spontaneous 
perforation of the cornea. In such cases we may have 
neuralgia of the eye first affected, or sympathetic in- 
flammation of the second eye. Iridectomy is then of 
great benefit, for by this operation we can abscise the 
imprisoned bit of iris, as well as the crushed ciliary 
nerves, and succeed in saving both eyes from danger. 
But when the incarceration of the iris has already 
induced irido-cyclitis, or when the latter affection has 
originated from any cause whatever, iridectomy is of 
no avail, and cannot in any respect be advantageously 
resorted to as a substitute for enucleation. 

When the sympathetic symptoms can be attributed 
to the crushing of the nerve during enucleation, or to 
secondary imprisonment of the stump of the nerve in 
the cicatrix, we may endeavor to remove the irritating 
cause by subsequent excision of the cicatrix. But 
even then we shall only gain permanent results under 
the same circumstances under which enucleation would 
originally have been beneficial. Thus, Hasket Derby 
reports a case of fully-developed irido-cyclitis which 



190 SYMPATHETIC DISEASES OF THE EYE. 

could not be cured by resection of tHe stump of the 
nerve (page 154) ; while, on the other hand, Mooren 
succeeded in permanently relieving the ciliary hyper- 
sesthesia in his case (page 153) by some peculiar* 
method' (which may really have consisted in exsecting 
the stump of the nerve). In my own case (page 136) I 
proposed an operation to the patientj intending to dis- 
sect the optic nerve away from all its surrounding tis- 
sues as far back as the optic foramen, and then to 
abscise it. If the irritating cause were situated in the 
orbital portion of the nerve, we might, perhaps, suc- 
ceed in relieving the tormenting pain from which the 
patient has suffered. Up to this time, however, my 
patient, to whom, of course, I could not guarantee per- 
fect success, has not been able to make up his mind to 
consent to the operation. 

We have now finished our discussion of the opera- 
tions which may be practised upon the eye originally 
affected, but we have not yet exhausted our account 
of the operative therapeutics of sympathetic ophthal- 
mia. We still have to inquire what operations, if any, 
are permissible on the eye which has become affected by 
sympathy. In these cases also it is important for us 
to separate the various forms and stages of sympathy. 
We cannot operate on the second eye so long as it is 
intact, or merely exhibits simple irritation, or slight 
functional disturbances. 

Iritis serosa is the first affection of the uveal tract 



THERAPEUTICS. 191 

that we are to consider. In general, this type of 
iritis will not need any heroic treatment, and we 
ought to act toward it with much greater reservation 
than in a case of the same disease which does not de- 
pend upon sympathetic irritation. For the sympa- 
thetic form is evidently dependent upon some irritation 
of the nerves, an irritation whose increase we dread so 
exceedingly that we always energetically oppose enu- 
cleation of the irritating eye, so long, at least, as the 
iritis serosa persists. When the common form of 
serous iritis continues for a long time, and will not 
yield to the usual remedies, we cannot do anything 
better than to perform iridectomy. But, just as we 
should not operate on an eye affected by sympathy so 
long as there seems to be no real danger from delay, 
so we should not be too hasty in performing an iridec- 
tomy in cases of sympathetic serous iritis. As v. 
Graefe said, in 1866 : " I remember only two cases in 
which I felt obliged to perform paracentesis of the 
cornea, and once to perform iridectomy upward, in 
cases of obstinate iritis serosa. In all of these, how- 
ever, the desired purpose was effected." 

Simple plastic iritis with but few posterior adhe- 
sions of the pupillary margin, the intermediate por- 
tions of the iris reacting well to atropia, is to be 
placed on the same level with serous iritis, so far as 
the abstinence from operative treatment in sympa- 
thetic irritation is concerned. 



192 SYMPATHETIC DISEASES OF THE EYE. 

We have, however, an exceptional state, of affairs 
in cases of- total exclusion of the pupil by circular pos- 
terior adhesions. Let us at this point recall our pre- 
vious remarks on this subject (pages 76 and 80). The 
differential diagnosis between the condition in which 
the iris is bulged forward by the fluid of the posterior 
chamber on the one hand, or by the masses of exuda- 
tion dependent on plastic irido-cyclitis on the other, 
lies chiefly, in our judgment, in the degree of hardness 
or softness of the eyeball, in comparison with the nor- 
mal condition. If the fluids of the posterior chamber 
have bulged the iris forward, the eye will be doubt- 
fully, or perhaps distinctly harder to the touch ; if exu- 
dations have been at work, the eye will be decidedly 
soft. When the periphery of the iris is bulged for- 
ward in knob-like masses, the eyeball, however, being 
soft to the touch, the case is quite different from that 
in which, with similar appearances on the part of the 
iris, we can prove that the eye is harder than normal. 
This latter condition only is the one with which we are 
now concerned. 

The literature at our command does not give a su- 
perfluity of advice for cases in which sympathetic sec- 
ondary glaucoma is apprehended, or in the presence of 
symptoms which denote its approach. V. Wecker 
(1879) thinks that, " on account of the violent pain 
from which the patients often suffer in case of an at- 
tack of glaucoma after the development of complete 



THERAPEUTICS. 193 

posterior adhesions," we should confine ourselves ex- 
clusively to paracentesis of the cornea or sclerotomy ; 
we should never think of touching the iris, or of per- 
forming iridectomy. " We shall not, as a rule, suc- 
ceed," says he, " in loosening those fragments of the 
iris which adhere to the anterior capsule of the lens, 
and if we are so fortunate as to succeed in a few cases, 
the eye will be so much irritated by the contusion, that 
the momentary benefit which we seem to have won will 
be lost again by closure of the new pupil, and deterio- 
ration of the function of vision." 

Unfortunately, I cannot assent to this view ; for in 
cases of simple iritis, iridectomy is unnecessary, while 
in those in which the posterior surface of the iris has 
become adherent to the anterior capsule, the oper- 
ation is hardly practicable. But in that condition 
of affairs which we are now discussing, there is no 
doubt that we can excise a piece of the iris with the 
effect of restoring the communication between the an- 
terior and posterior chambers. By this means we may 
also successfully oppose the inflammatory attacks of 
secondary glaucoma, as well as of glaucoma itself, by 
removing the inducing cause. The following instruc- 
tive clinical history may serve to throw light upon 
what we have just said. 

A man about thirty-one years of age was seen at the 
Clinic April 30, 1876. On January 24, 1876, a cramp- 
iron had been projected against his left eye. The 
9 



194 SYMPATHETIC DISEASES OF THE EYE. 

patient suffered but little pain after the injury; the 
sight of the wounded eye was diminished, but he could 
still see pretty well. The eye was very sensitive to light, 
and a few days thereafter it began to redden. The 
"inflammation" passed off in a fortnight, but vision 
had at that time diminished still further. The patient 
kept at his work for another fortnight, but as it made 
the eye congested and painful, he applied a bandage 
over it and stopped work. Still a fortnight later, six 
weeks in all, after the injury, the right eye became 
affected, and was injected and painful. The inflam- 
mation continued with occasional exacerbations, so 
that vision was gradually reduced to its present amount. 
The examination shows the following state of things 
in the left eye : A cicatrix, three or four millimetres in 
length, in which the iris has become incarcerated, lies 
in the sclerotica, at the outer edge of the cornea, just 
above its horizontal diameter. The iris, which is al- 
tered in color, and has partially lost its striated ap- 
pearance, is tied down to the anterior capsule of the 
lens by numerous adhesions, whilst the pupil has been 
elongated toward the cicatrix in such a manner that it 
seems as if a regular iridectomy had been performed. 
The ophthalmoscope reveals the bright edge of the 
crystalline lens at the place where the iris is deficient. 
We know, therefore, that the lens was not dislocated 
by the injury. The vitreous is so full of floating 
opacities that we cannot get an image of the back- 



THERAPEUTIC8. 195 

ground of the eye. The whole ciliary region is slightly 
congested. The tension of the eye is not noticeably 
changed ; i.e., the eye is neither too soft nor too hard. 
Tactile exploration shows that the outer and upper 
portion of the ciliary region (not precisely in corre- 
spondence with the place where the iris is incarcerated) 
is sensitive to pressure. The sight of this eye has 
decreased to one-fourth, or, with a very weak concave 
glass, to one-third of the normal amount. 

The right eye shows slight injection of the ciliary 
region. The pupil is completely excluded by poste- 
rior adhesions, and the periphery of the iris bulged 
forward, especially in the upper half of the iris, which 
is altered in color and appearance. The pupil is filled 
with a membrane which is thin and transparent at the 
centre, but thick at the circumference. The tension 
of the eye is perceptibly increased, but not to a high 
degree. A sensitive spot, corresponding precisely in 
location to the one discovered in the left eye, is found 
by careful palpation. Vision is reduced to one-seventh 
of the normal amount. 

What are we to do % We cannot enucleate the in- 
jured eye, even did it possess only the slightest possible 
trace of vision. It is as clear as possible that we can- 
not enucleate one eye with one-third of normal vision 
in order to save the other, which at present has only 
one-seventh of normal vision, not even if we had any 
faith whatever in the efficacy of enucleation under* 



196 SYMPATHETIC DISEASES OF THE EYE. 

such circumstances. On the other hand, I am re- 
strained from operating on the eye sympathetically 
affected, by the dread which such an operation should 
always inspire. 

The patient is sent to bed, receives a solution of 
atropia for his left eye (without, however, dilating the 
pupil), and a course of inunction is begun. A week 
later (May 6th), after three inunctions (not to these, 
but to the suitable regimen do I ascribe the benefit) 
the ciliary injection has disappeared from both eyes. 
The ciliary body in each eye is no longer sensitive to 
the touch. On the next morning, however, pain is felt 
in the right eye, increases all day long, and at night 
becomes very violent. May 8th. — The tension of the 
right eye (the one affected by sympathy) is noticeably 
increased, the lids are slightly swollen, ciliary injection 
is excessive, the cornea is slightly hazy, and the iris is 
bulged forward much more than at any previous time. 
Pain is also felt at the sensitive spot in the ciliary region 
(while the corresponding spot in the wounded eye is free 
from pain), and vision is reduced to counting fingers 
at one metre. In brief, the right eye exhibits all the 
symptoms of acute glaucoma. May 12th. — As vision 
has not increased, an iridectomy is made inward, a 
large piece of iris being excised. The incision heals, 
and the anterior chamber is restored. The iris no 
longer bulges forward at its periphery, but lies in a 
plane. The blood in the anterior chamber is soon 



THERAPEUTICS, 197 

absorbed, pain and sensitiveness of the ciliary body 
disappear, and tension becomes normal ; but the ciliary 
injection is still present (May 18th). 

June 9th. — Both eyes are perfectly free from irri- 
tation, and their tension is normal. Eight eye : The 
cornea is slightly cloudy near the cicatrix left after 
the incision, but is otherwise transparent. . The newly 
formed pupil is partially covered with a membrane, 
which, however, permits light to enter the eye at its 
periphery. The iris lies in its normal position. Left 
eye: The floating opacities in the vitreons have de- 
creased so much that the retinal vessels and optic papilla 
can be dimly seen by means of the ophthalmoscope. 

The result of the case may be thus formulated in 
brief : The injured left eye has one-half of normal 
vision; the sympathetically affected right eye, one- 
tenth of normal vision. 

" I always operate when the periphery of the iris 
bulges forward," as I said before in speaking of sec- 
ondary glaucoma produced by sympathetic iritis. This 
operation consists, as is evident from the foregoing 
clinical case, in iridectomy, which has an undeniably 
beneficial effect. Sclerotomy, i.e., the formation of a 
large wound in the sclerotica at the edge of the cornea, 
cannot be performed under the above circumstances 
(bulging of the iris), owing to the excessive protrusion 
of the periphery of the iris ; while, on the other hand, if 
it could be performed, it would not fulfil the indication 



198 SYMPATHETIC DISEASES OF TUE EYE. 

of restoring the communication between the anterior 
and posterior chambers. 

Secondary glaucoma after sympathetic iritis seems 
to me to be the only condition that allows of operative 
interference. For, as serous iritis, as well as plastic 
iritis, does not demand such treatment, in the same 
way we cannot operate during the height of irido- 
cyclitis, because by so doing we increase the morbid 
process which in turn rapidly leads to atrophy of the 
eye. The unfavorable results which I had obtained 
from iridectomy, when performed under such circum- 
stances, led me over to the side of the large majority 
of oculists of the present day, who will not resort to 
any operation, not even to an iridectomy, in cases of 
plastic irido-cyclitis. When v. Graefe performed iri- 
dectomy " even in a simple condition of affairs," but 
like all other operators gained no beneficial results, he 
asked himself whether " the iridectomy might not have 
been performed at too late a date." Or whether " a 
broad excision of the iris toward the extreme peri- 
phery might not be of greater benefit, especially if 
we reflect, that when the iris has once begun to ad- 
here to the anterior capsule of the lens, the adhesion 
advances rapidly toward the ciliary processes." In 
other words, v. Graefe inquired whether, if he made 
the incision in the sclerotica as in the cataract oper- 
ation which goes by his name, the iris would not pre- 
sent itself more broadly, and in a more suitable po- 



THERAPEUTICS. 199 

sition for being grasped by the forceps, so that a much 
larger piece might be excised. 

V. Grraefe's recommendation of such a method is 
based on the favorable result which he obtained in one 
case of this sort — the only one which he had oppor- 
tunity of reporting up to that date. But many ocu- 
lists have since discovered that v. Graefe's hopes were 
too sanguine. Mooren, for example (1869), expresses 
doubt whether even the earliest and most successful 
iridectomy can be of any avail at all in the malignant 
type of plastic irido-cyclitis, for in two cases in which 
he performed the operation at the very outbreak of 
the disease, and under relatively favorable circumstan- 
ces, the result was fatal to vision. 

Although a few cases of the favorable effects of one 
or repeated iridectomies in iritis maligna have since 
been reported (lingo Miiller, Grossmann, Pniiger), we 
must hold firm to the axiom, that only after the pro- 
cess has become entirely extinct (by no means sooner 
than a year after the outbreak of the sympathetic in- 
flammation) can we decide whether an operation is to 
be undertaken or not. The condition of the eye after 
such a lapse of time is frequently a great deal more 
favorable than we should have deemed possible at the 
outbreak of the affection, and many an eye that a few 
■weeks after the appearance of iritis maligna seemed to 
have fallen a prey to total atrophy, offers itself, at the 
end of a year, free from irritation, with proportionally 



200 SYMPATHETIC DISEASES OF THE EYE. 

fair tension, and prompt quantitative reaction to light, 
even when the pupil is blocked up ; or, when the pu- 
pil is clear, or but slightly veiled, exhibits a surpris- 
ing degree of vision. In the latter case, we should 
be well on our guard against operating with the inten- 
tion of improving sight. In the former, on the con- 
trary, we should not delay in our attempt to make a 
path for the rays of light to reach the retina. In such 
cases, however, we cannot expect any benefit from 
simple iridectomy, for the whole surface of the iris 
being adherent to the capsule of the lens, it is impos- 
sible to draw or tear away the iris with its adherent 
membranes. We can then only attain our object by si- 
multaneously opening and removing the anterior cap- 
sule, giving rise at the same time to traumatic cata- 
ract. In other words, we must resort to " extraction 
of the lens, with simultaneous iridectomy and lacer- 
ation of the false membranes." (Y. Graefe.) 

A narrow knife — e.g., v. Graefe's cataract-knife — is 
entered at the upper and outer edge of the cornea, 
nearly on a level with the tangent of the highest point 
of its upper margin. It is next to be pushed through 
the iris, afterward behind the iris, and finally through 
the lens to a corresponding point of counter-puncture, 
so that the sclerotic coat is opened at the upper edge 
of the cornea by a linear incision ten millimetres in 
length. We then introduce the forceps in such a 
manner that one branch passes in front of the iris, the 



THERAPEUTICS. 201 

other behind it (really into the lens behind the ante- 
rior capsule, which is adherent to the iris), and try to 
draw the whole membranous mass between the lips of 
the incision, in order to excise it. In case the mem- 
branes will not follow the traction (we should not 
pull too forcibly), we must cut through the mem- 
branes, with a pair of fine scissors, in such a manner 
that a free triangular bit of membrane lies between 
the branches of the forceps, by means of which the 
bit can be removed from the eye. Then follows the 
evacuation of the lens, which, during this manipula- 
tion has already been broken up into small pieces. If 
the opening in the membranous iris closes again after 
the operation, or if irido-cyclitis attacks the eye which 
has lost its lens, we should (after opening the an- 
terior chamber with v. Graefe's knife) simply divide 
the diaphragm by v. "Weeker's forceps-scissors, one 
branch being passed through the iris and behind it, 
and the other lying in front between the cornea and 
the iris (iritomy). In the case described on -pages 52 
to 55, double iritomy enabled the eye affected by sym- 
pathy to see fingers at six feet (with proper cataract- 
glasses), while the other eye gained vision equal to one- 
eighth of the normal amount.* 

* Pagenstecher (1881) is of the opinion that such an operation 
as is here described is a mistaken one, and that we can win much 
better results by making an iridectomy, and then removing the 
lens, together with its capsule, with a flat spoon. — Ths. 
9* 



202 ' SYMPATHETIC DISEASES OF THE EYE. 

Little as we can expect from the operative treat- 
ment of sympathetic inflammation when this disease 
has once become well defined, and extremely probable 
as it is that more benefit can be obtained by refrain- 
ing from operative interference, we have no reason to 
boast of the results of medical treatment. Serous 
iritis and simple plastic iritis (in and by themselves 
by no means greatly to be dreaded, as we have repeat- 
edly urged) behave toward therapeutical measures like 
other types of iritis which are not of sympathetic 
origin. But therapeutics have no power over a genuine 
sympathetic irido-cyclitis. It is, indeed, extremely 
doubtful whether even the most energetic measures, 
whether mercurialization, or even acute mercurializa- 
tion, in a case of the latter type, can save an eye, 
which, on the other hand, may recover without any 
employment of mercury whatsoever. 

We may thus sum up our therapeutical resources in 
cases of injuries of the eye which may subsequently 
lead to sympathetic inflammation. If an eye is badly 
injured, a large portion of its contents evacuated, 
vision totally lost, and a foreign body undoubtedly 
present in its interior, it is best to enucleate at once, 
before the impending panophthalmitis makes its ap- 
pearance. If the wound embraces a large extent of 
the eye, and we are sure that no foreign body remains 
behind (or, if the shape of the eye as well as a partial 
amount of vision has been preserved, even if it is 



THEKArEUTICS. 203 

probable that a foreign body is. still lodged within the 
eye), we are not to be in too great haste to enucleate. 
We should rather put the patient to bed in a darkened 
room, and drop a solution of atropia into the eye at 
regular intervals. If we think it can still be .of any 
avail, we should further add a compress-bandage ; and 
lessen whatever pain is felt, by hypodermic injections 
of morphia. The application of iced compresses, as 
well as of leeches, notwithstanding their frequent 
employment, is really of doubtful benefit. It is only 
in the exceptional cases in which the patient cannot 
bear the pressure-bandage that we should resort to 
cold applications. We should, however, remove them 
the moment that they begin to feel disagreeable to 
the patient, and simply cover the eye gently with a 
bit of cotton cloth. If panophthalmitis ensues, we 
should leave the pressure-bandage on as long as the pa- 
tient can bear it; afterward warm fomentations (thin 
compresses dipped in warm tea, or poultices of farina- 
seed or wheat-bread boiled) are indicated. We may 
also try Lelievre's new poultice-papers, which are 
strongly recommended by Fronmiiller. 

When the eye becomes purulent, excessively pain- 
ful, and greatly swollen, we may attempt relief by 
opening it. But when the panophthalmitis begins to 
show signs of relapse, we should, as soon as possible, 
insist upon the renewed application of the compress- 
bandages. 



204 SYMPATHETIC DISEASES OF THE EYE. 

If several weeks have passed since the injury (the 
patient having been kept perfectly quiet in the inter- 
val) and the panophthalmitis has diminished propor- 
tionately, we must examine the eye thoroughly to see 
whether it is now perfectly quiescent or not. If it 
should be quiescent, the patient may have our consent 
to resume his usual occupation, but should be warned 
most earnestly to take notice of the least return of pain 
in the injured eye, and to report for advice without a 
moment's loss of time. If, on the other hand, the eye 
is no longer spontaneously painful, but still continues 
sensitive to all slight external influences, as well- as 
sensitive or painful to pressure, we should enucleate it 
at once. We should also enucleate the eye, even if it 
still possesses a slight amount of vision, provided that 
it cannot be securely guarded from noxious influences, 
or if we cannot rely upon the intelligence of the pa- 
tient. But if the patient be thoroughly intelligent, 
we can point out to him the various symptoms and 
circumstances under which he should at once seek 
surgical advice. 

As soon as the stage of sympathetic irritation has 
become pronounced, we should instantly enucleate, 
even if the injured eye still preserves vision. In 
serous iritis, as well as plastic iritis with only a few 
adhesions, we should never enucleate, but keep the pa- 
tient under the most guarded regimen : rest in bed in 



THERAPEUTICS. 205 

a darkened room, regulation of the diet, together with 
care for easy evacuation of the bowels. Locally, we 
should resort to solutions of atropia. If the eye is 
painful, and the circumcorneal injection well pro- 
nounced (which conditions are, however, very rare in 
iritis serosa), we should try bloodletting at the tem- 
ples, as well as poultices applied to the eye. Weeks, 
or even months later, when the iritis has wholly disap- 
peared we may enucleate as a preventive of future 
evil, in case the exciting eye has not become wholly 
free from pain. If the inflammation has culminated 
in posterior adhesions, with bulging of the peripheral 
portions of the iris, and subsequent secondary glau- 
coma, we cannot rely upon the usual anti-glaucoma- 
tous remedies, such as eserin sulphate, pilocarpin mu- 
riate (in one per cent, solutions), but we must try to 
restore the communication between the two chambers 
by an iridectomy. 

Genuine plastic irido-cyclitis demands, of course, 
the above-mentioned strictness of regimen, and the 
most abundant patience, as well on the part of the 
surgeon as of the sufferer. Bloodletting and atropia 
seem to do more harm than good in this type of the 
disease. We can best resort' to repeated poultices, 
and (if necessary) to morphia injections. If the pa- 
tient consents, we may try acute mercurialization, aim- 
ing to saturate the system with mercury in the shortest 



206 SYMPATHETIC DISEASES OF THE EYE. 

possible time. For this purpose, from six to ten 
grammes ( 3 iss.- 3 iiss.) of gray mercurial ointment 
should be rubbed in daily, conjoining this treatment 
with the internal exhibition of calomel in one to two 
decigramme doses (grs. iss-iij.) every two hours until 
salivation is produced. But inasmuch as irido-cyclitis 
rarely leads precipitately to unfortunate results, a com- 
mon well-regulated course of inunction seems to me 
altogether more suitable. We ought to try this treat- 
ment in order to satisfy our consciences. But we should 
not expect too flattering results. If we carefully 
analyze the few reported cases of rapid and perfect 
cure effected by acute mercurialization after previous 
enucleation, we shall discover, without the shadow of a 
doubt, that the cases were not genuine irido-cyclitis, 
and that therefore this type of disease was not cured 
by mercury. If or can we attribute any decidedly favor- 
able influence to the enucleation. This operation, by 
the way, we can omit with a calm conscience under 
the circumstances here mentioned. The sympathetic- 
ally affected eye may, if it has not become blind, be 
subjected to an operation at a future time. 

We have now finished our account of the therapeu- 
tical measures which may be adopted in the severest 
forms of sympathetic ophthalmia (affections of the 
uveal tract), but we have yet to say something of the 
remedies which may be employed in the secondary or 



THERAPEUTICS. 207 

minor forms of this insidious affection. Sympathetic 
retinitis or neuro-retinitis, which ensues in company 
with inflammations of the uveal tract, cannot, on the 
whole, have any influence in inducing us to change our 
indications for operative interference, notwithstanding 
the few reported cases of sympathetic keratitis and 
scleritis have always been known to disappear after 
enucleation. This form of sympathy should be treated 
by rest, darkness, bloodletting, inunctions, and the 
iodide of potassium. Shall we enucleate if it is diag- 
nosticated as being independent of any uveal affec- 
tion? I am of the opinion that sympathetic neuro- 
retinitis is due to a similar morbid process in the oppo- 
site optic nerve and retina. Inasmuch, therefore, as 
the division of an inflamed nerve does not seem any 
too seductive to me, and as a relatively great number 
of these cases have been observed directly after 
enucleation (showing that the deleterious influence of 
the division, or of the cicatrix, upon the nerve can 
hardly be denied), I would not like to enucleate in 
a case of sympathetic neuro-retinitis, despite those 
favorable results which have been reported. Several 
cases of sympathetic retinitis were reported at the In- 
ternational Ophthalmological Congress, in New York 
(1876), by Alt, Derby, and Risley. Alt saw rapid im- 
provement and recovery after enucleation in one of 
his three cases. But it seems to me that the sympa- 



208 SYMPATHETIC DISEASES OF THE EYE. 

thetic origin of these cases was not accurately demon- 
strated, for the optic nerve of the enucleated staphy- 
lomatous eye showed deep glaucomatous excavation 
and atrophy. Moreover, several observers besides 
myself have seen a sympathetic retinitis disappear 
spontaneously, under suitable circumstances. 



INDEX. 



A BSCISSION of cornea as a substitute for enucleation, 188 
Accommodation, 16 

11 asthenopia of, 62 

" impairment of, 68 

Amblyopia, sympathetic, 97 
Anaesthesia of retina, 66^ 128 
" sympathetic, 105 
Anaesthetics' during enucleation, 176, 177 
Anatomy of ciliary nerves, 57, 58 

'I eye, 12 

Anterior capsule, 13 

" incarceration of, in wound of eye, 42 
" chamber, 13 
Aqueous humor, 13 

" " imprisonment of, behind iris, 78 

u normal means of escape of, 77 
Artificial eyes, description and mode of adaptation of, 150, 151 

" " as cause of sympathetic ophthalmia, 51, 70, 134, 136, 151 

Atrophic choroiditis, 86, 92 
Atrophy of ciliary nerve3, 119 
eye, 28 
" optic nerve, 119, 128 

Atropia, 196, 203 



"DANDAGE, compress, 175 

Blepharoraphy as a substitute for enucleation, 188 
Blepharospasm, 59 

Blindness, total, from repetition of original injury, 9 
Blood effused into retina, 88 
Blows on eye, 25, 52 



210 IND2X. * 

Z^IANAL of Fontana, 16 
^ " Sohlemm, 16 

Capsule of Tenon, 150 
" lens, 13 

" " shrivelling of, 42 

Case of arrow-wound of eye (Mauthner), 21 

" bit of iron encapsuled-nine years in ciliary muscle (Bowen), 24 
" " metal lodged seventeen years in optic nerve (Bowen), 25 

u cataract operation producing sympathy (Mauthner), 39 
u double operation for cataract (Knapp), 41 
" enucleation after linear extraction of cataract (Mauthner), 39 
for iritis serosa (Mooren), 154 
" " (Derby), 154 

" " (Knapp), 155 

" " refusedbypatient(Samelsohn),156 

with unsuccessful result (Gayet), 165 
hemorrhagic glaucoma (Pagenstecher), 100 
herpes zoster ophthalmicus producing sympathy (Jeffries), 44 
" " " (Noyes),44 

horse bite of eye producing sympathy (Mauthner), 29 
injury of ciliary body from bit of iron (Mauthner), 18 
" eye by a cramp-iron (Mauthner), 193 
" " from a bit of glass (Mauthner), 23 

iridodesis producing sympathy (A. Graefe), 35 

" " " (Steffan), 36 

leech bite of eye producing sympathy (Lebrun), 30 
lodgment of bit of metal in posterior chamber (Mauthner), 19 
neurotomy for sympathetic neuro-retinitis (Bheindorf), 178 
peri-neuritis of optic nerve producing sympathy (Mooren), 132 
persistent photopsies, despite enucleation (A. Graefe), 65 
poliosis arising from sympathy (Shenkl, Jacobi), 85 
primary lesion of optic nerve (Brailey), 126 

" neuro-retinitis (Williams), 126 
resection of stump of optic nerve after enucleation (Derby), 

154 
reunion of nerves after neurotomy (Mauthner), 185 
sudden death associated with a proposed iridectomy (Trans- 
lators), 148 
sympathetic choroido-retinitis (v. Graefe), 87 

88 
u contraction of field of vision (Brecht), 67 
" ophthalmia after recovery from cyclitis (Mauth- 
ner), 52 
sympathetic ophthalmia from enucleation (Colsmann), 93 
" " " " (Mooren), 94 



INDEX. 211 

Case of sympathetic ophthalmia from enucleation (Miiller), 94 
" " " " (Vignaux), 158 

" " " " ganshot wound (Oohn), 49 

" wound of eye by a cow's horn, producing sympathy (Mauth- 
ner), 136 
Cataract, cases of cyolitis after operations for, 39, 40, 41 
" causes of original irritation in eyes treated for, 43 
" depression (or recliuation) of, 37 
" division of, 37 
" extraction of, 37 
" flap operation for, 38 
" lamellar, 33 

" modified linear extraction of, 39 

" operations for, causes of sympathetic ophthalmia, 81, 39, 103 
u stationary central, 31 
" sympathetic, 103 
Cellular plate of ligamentum pectinatum iridis, 13 
Chiasma, relations of optic nerves at, 106 
Choroid, 15 

" peculiar form of morbid patches in, 86 
Choroidal sarcoma, 43 
Choroiditis, 38 

" atrophic, 86 

" purulent, production of, as a substitute for enucleation, 1S6 

Choroido-retinitis, 87, 88 
Ciliary body, 15 

" detachment of, 43 
" ' diseases of, 17 
" foreign objects encapsuled in, 34 
" injuries of, 17, 33, 35, 36, 43, 65 
" " spontaneous cure of, 17, 18 

" " symptoms and anatomical changes caused 

by, 26 
ganglion, 58 
muscle, 15 
nerves, anatomy of, 57, 58 

" as conductors of sympathy, 110-120 
" atrophy of, 119 

" composition and functions of, 57, 58 
" reunion of, after neurotomy, 183 
neuralgia, 63 
Circle of Willis, 109 
Compress bandage, 175 
Cornea, 13 

" abscission of, as a substitute for enucleation, 188 



212 



INDEX. 



Cornea, curvature of, impaired by iridodesis, 34 

" paracentesis of, 193 

u phlyctenule of, 59 

" staphyloma of, 45, 46 
Creed (Mauthner's) prescribing and limiting enucleation, 170 
Crystalline lens, 12 
Cyclitis, 26, 29 

" acute, Mooren's definition of, 29 
Cyclo-choroiditis as a cause of sympathetic ophthalmia, 46 
Cysts of iris as a cause of irido -choroiditis, 43 
Cysticerci, intra-ocular, 43 



TAEATH, after enucleation, 147, 160 
"^ Descemet's membrane, 13 

" " deposits on, in serous iritis, 74 

Detachment of retina, 28, 103 

u ciliary body, 42 

Diagnosis of sympathetic ophthalmia, 144 
Diffused light, disturbance of vision by, 32 
Diseases, sympathetic, list of, 56 

" " ' relative severity of, 102 

Drainage of eye, as a cause of sympathetic ophthalmia, 104 

" " operation of, described, 103 



TpARLIEST advent of sympathetic ophthalmia, 142, 143 
Enucleation, accidents from, 147, 149, 152, 159 
after-treatment of, 175 
anaesthetics during, 176 
as a cause of death, 147, 160 
" " disfigurement, 149, 151 
" " sympathetic ophthalmia, 51, 62, ! 
132, 155 
creed indicating and contraindicating, 170 
crushing of optic nerve during, 162 
indications for and against, 163-170, 202-206 
in irido-cyclitis, 169 
" iritis maligna, 159 
" " plastica, 168 
" " serosa, 167 
" panophthalmitis, 160 
of left eye, 171 
" right eye, 175 
" wrong eye, 175 



INDEX. 213 

Enucleation, operation described, 171 

preventive, 163, 164, 166, 170 
Eserin, sulphate, 205 
Etiology of sympathetic ophthalmia, 17 
Exclusion of pupil, 76, 192 
Exenteration of orbit, 171 
Exsection of stump of optic nerve, 154, 189 
Eye, anatomy of, 12 

" artificial, as a cause of sympathetic ophthalmia, 51, 70, 134, 151 

" " description of, 150 

" " motion of, 151 

" drainage of, 103, 104 -. 

" phthisis of, 28, 100 



TJ^IEI/D of vision, contraction of, 66 

" " " concentric, 67, 128 

" " obscuration of, 66, 127 

" " " " rhythmical, 66 

Fontana's canal, 16 

Foreign bodies in eye, 18-25 

Fovea centralis, 15 



p LAUCOMA, 46, 95 
^- 3r " acute, 99 

" as a cause of sympathetic ophthalmia, 46 

" definition of, 95 

*' iridectomy in, 193 

" secondary, 78, 198 

" sympathetic, 95-101 

" " hemorrhagic, 100 

without inflammatory symptoms, 98 
Glioma of retina, 43 

Gonorrhceal ophthalmia, causing sympathetic ophthalmia, 50 
Gunshot wounds of eye, 49 



"TIT HEMORRHAGIC extravasations into retina, 50, 

" sympathetic glaucoma, 100 

Herpes zoster, 44, 113, 115 
Hyperesthesia ciliaris, 153 

" of retina, 62, 66, 68, 128 

Humor, aqueous, 13 



214 INDEX. 

Humor, aqueous, imprisonment of, behind iris, 78 
44 " normal meanB of escape of, 77 

" vitreous, 12 



TNTRA-OCULAR neurotomy, 178, 181 

Iridectomy, as alleged cause of death, 148 

" " cause of sympathetic ophthalmia, 42 

" indications for, in iritis maligna, 199 

u in glaucoma,. 193 

" 44 sympathetic ophthalmia, 189 

41 Pagenstecher's modification of, 201 

Irido-choroiditis, as cause of detachment of retina, 133 
" from cerebro-spinal meningitis, 44 

" " herpes zoster ophthalmicus, 44 

" " syphilis, 44 

Irido-oyolitis, 43, 107 

" sympathetic, 36, 43, 100, 169 
Irido-cyclo-choroiditis, 26-2S 

Iridodesis, as a cause of sympathetic ophthalmia, 35, 36, 37 
" in dislocated lens, 34 

" operation of, 33 

" Pagenstecher's modification of, 34 

Iris, 13 
" bulging forward of, in exclusion of pupil, 192 
" prolapse of, as cause of sympathetic irritation,' 48 
44 4l in perforating ulcer of cornea, 45 

" " in wounds, 29 

Iritis maligna, 80, 84, 159 

" plastica, 75, 80, 157, 168, 191 
" (serosa, 71, 75, 80, 102, 167, 190 
44 44 simplex, 75 

44 sympathetic, relationship of different forms of, 81 
Iritomy, 201 
Irritation, simple, of eye, 59, 60 

41 dangerous form of, 60, 61, 68, 102, 166 
44 relation of, to inflammation, 6S, 69 



T7"ERATITIS, after paralysis of trigeminus, 113 
■*■*- " sympathetic, 69, 207 

intermittent, 70 
Kerato-conjunctivitis, sympathetic, 48 
Kerato-iritis, sympathetic, 70 



INDEX. 215 

T ENS, crystalline, 12 
" dislocation of, 34 

" " as a cause of irido-choroiditis, 43 

Ligament, suspensory, 12 

" " laceration of, 34 

Ligamentum pectinatum iridis, 13 
Linear extraction of cataract, 39 

" " causing sympathetic ophthalmia, 41, 103 



TV/TEMBRANE of Descemet, 13 

" " deposits on, in serous iritis, 74 

Mercury in sympathetic ophthalmia, 196, 202, 205 
Motion of artificial eye, 150 
Motor fibres of ciliary nerves, 58 



"NTEOPLASM attached to optic papilla, 22 
Nerves, ciliary, anatomy of, 57, 110 

" as conductors of sympathy, 110-120 
" atrophy of, 119 
Nerve, naso-ciliary, 57 
" optic, 14 

" " as conductor of sympathy, 110, 118, 120, 122 

" " atrophy of, 119 

u " excavation of intra-ocular end of, 97 

u u hyperplasia of intra-ocular end of, 65 

Neuralgia, ciliary, 63 
Neuro-retinitis, sympathetic, 133 

" " " treatment of, 207 

Neurotomy, 177 

" as a preventive of sympathetic ophthalmia, 186 

" ciliary, 181 

" extra-ocular, 180 

a u general remarks on, 181 

" " history of, 177 

" " method of performing, 183, 184 

" " reunion of nerves after, 182 

" intra-ocular, 178, 181 



/"VBLIQUE illumination of eye, 72 
^^^ Occlusion of pupil, 76 
Optico-ciliary neurotomy, 180 
Optic nerve, 14 

" " as conductor of sympathy, 65, 108, 121, 126, 130, 132 



216 INDEX. 

Optic nerve, atrophy of, 119, 128 

" " excavation of in tra-ocular extremity of , 95, 97 

" " mode of crossing of, at chiasma, 106 

" " sympathetic affections of, 92 

" papilla, 14 
Ora serrata, 14 
Orbital cellulitis after enucleation, 149 



"PANOPHTHALMITIS, 47, 147, 203 
- 1 - " enucleation during, 160 

Paracentesis of cornea, 193 
Pars ciliaris retinse, 109 
Pathogeny of sympathetic ophthalmia, 105 
Pathology of sympathetic ophthalmia, 56 
Phlyctenule of cornea, scrofulous, 59 
Photophobia, 59, 64, 128 
Photopsia, 59, 64, 128 
Phthisis of eye, 28, 100 
Pigment spots in retina, 89, 92 
Pilocarpin, muriate, 205 
Plastic iritis, 75, 80, 157, 168, 191 
Poliosis, sympathetic, 85 
Posterior capsule, 12 
11 chamber, 14 
Poultice-papers, Lelievre's, 203 
Preliminary remarks, 10 
Pressure points, 84, 85, 113, 195 
Prognosis of sympathetic ophthalmia, 145 
Pupil, exclusion of, 76, 192 
" occlusion of, 76 



QUESTION of enucleation in sympathetic ophthalmia discussed, 
146-177 
Question of neurotomy in sympathetic ophthalmia discussed, 177-186 



"DEFLEX action in conduction of sympathy, 112 

Refracting media of eye, 12 
Retina, 14 

u anaesthesia of, 66, 128 

" detachment of, 28, 103 

" hsemorrhagio extravasations into, 50, 88 

" hyperesthesia of, 62, 66, 68, 128 



INDEX. 217 



Retina, irritation of, 62 
" pars ciliaris of, 109 
" pigment Bpots in, 89, 93 

Retinal gliomata, 43 

Retinitis, sympathetic, 87-92 

" treatment of , 207 



Q ARCOMA of choroid, 43 

Schlemm's canal, 16 
Sclera. See Sclerotica. 
Sclerotica, 13 

" softening, or relaxation of, 45 

" staphylomata of, 45, 46 

Scleritis. See Sclerotitis. 
Sclerotitis, 71, 207 
Sclerotomy, 193, 197 
Serous iritis, 71, 75, 80, 102, 167, 190 
Sight, impairment of, without structural lesion, 66 

" restored, of first eye, jeopardized by operation on other eye, 41 
Staphyloma of cornea, 45 
Staphylomata of sclerotica, 45, 46 
Strieker's experiments, 110 
Suspensory ligament, 12 

Symmetrically painful points on eyebills, 84, 85, 113, 195 
Sympathetic anaesthesia, 105 

" atrophy of optic nerve, 92 

tl cataract, 102 

'• choroiditis, 86 

" choroido-retinitis, 88 

" cicatrix, 105 

" diseases of eye, varieties of, 56 

" " " relative severity of, 80, 1 02 

" fibres of ciliary nerves, 58 

" glaucoma, 95-101 

" " acute, 99 

" :.- " hemorrhagic, lftO 

" " without inflammatory symptoms, 98 

" iritis, from enucleation, 82, 93 

" " maligna, 80 

" " " mode of propagation of, 107 

" " plastica, 76 et seq. 

" " serosa, 71 el seq. 

" irritation, 58-67 

" " after foreign bodies in oyo, 59 



218 iftDKX. 

Sympathetic irritation, as affected by enucleation, i66 
11 ll causes of, 61 

" " condition of second eye in, 62 

" " different forms of, 59, 60 

" " of optic nerve, 64, 65 

•' " of retina, 63, 64, 66 

" " removed by suppurative choroiditis, 188 

" . " with limitation of field of vision, 67 

lk " " impaired vision, 66 

" " " phlyctenules, 59 

keratitis, 48, 70, 207 
' ' opacities of vitreous humor, 102 
" poliosis, 85 
" retinitis pigmentosa, 92 
" sclerotitis, 71, 207 

1 ' ophthalmia, after recovery from cyclitis without atrophy 

of eyeball, 52-55 
" ophthalmia, diagnosis of, 144 

" " definition of, 10 

" from artificial eye, 51, 70, 134, 151 

" " " atrophy of optic nerve, 92 

" " " bit of iron encapsuled nine years in cil- 

iary muscle, 24 
u " " bit of metal lodged seventeen years in 

optic nerve, 25 
" kl u cerebro-spinal meningitis, 44 

" " " oyclo-choroiditis, 46 

" " " cysticeroi, 43 

11 " 4i detachment of retina, 47 

" " " drainage of eyeball, 104 

" enucleation of eye, 51, 62, 93, 132, 155 
" " " glaucoma, 46 

" " " glioma of retina, 43 

" " " gonorrhoeal ophthalmia, 50 

44 4t gunshot wounds, 49 

" " hemorrhage into vitreous humor, 47 

" " herpes zoster ophthalmicus, 44 

" " horse bite, 29 

" iridectomy, 42 
" " " irido-cyclitis, 43 

" " " iridodesis, 35, 103 

" leech bite, 30 

" mechanical injuries of ciliary body, 48 
" " " operations for cataract, 31, 39, 103 

" " " panophthalmitis, 47, 161 



INDEX. 219 

Sympathetic ophthalmia from prolapse of iris, 48 

" sarcoma of choroid, 43 
" " " syphilis, 44 

u ulcers of cornea, 45 
" exsection of optic nerve in, 189, 154 

" " iridectomy in, 189 

11 medical treatment of, 202 

'* relative frequency of, in the various cataract 
operations, 41 
" '' relative frequency of traumatic agencies pro- 

ducing, 26 
" " time of appearance of, 141 

" " without cyclitis, 51 

" " " disease of uveal tract, 51 

" " injury of ciliary body, 50 

Sympathy, means and methods of transmission of, 105, 132, 138 

" transmitted by the ciliary nerves, 110, 111, 115, 117, 118, 

120, 139 
" transmitted by the circle of Willis, 109 

" " by the optic nerves, 1C6, 117, 119, 127, 140 

" " by reflex action, 120, 125 

rpENON'S capsule, 150 

Tension of eye, definition of, 21 
Therapeutics of sympathetic ophthalmia, 146 
Transmission of sympathy by ciliary nerves, 110-120 
" " circle of Willis, 109 

" " optic nerves, 65, 108, 131, 12C, 130, 132 

Traumatic complications, in diseases of ciliary body, 17 
Tunics of eye, 12 

TTLCERATIVE prooess permitting prolapse of iris or of ciliary 
^ body, 45 
Uveal tract, 15 

" " acute purulent diseases ofj 46, 47 

" " idiopathic affections of, 43 

". " mechanical irritation of, 43 



"TTISION, impairment of, without anatomical changes, 66 

" " restored, of first eye, endangered by operation on second, 41 
Vitreous humor, 12 

" " filamentous opacities of, 102 

11 " molecular opacities of, 83 



220 INDEX. 

TTTILLIS, circle of, 109 
* Wounds of ciliary body, 17 
" eye, arrow, 21 
" " gunshot, 49, 50 68 



BLLOW spot, 15 



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ZONULA of Zinn, 12 
U (I 



laceration of, H4 




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wmMmmmm